Breakthrough Application Form

1

Please confirm your Full Name* This field is required.

First Name

Last Name

2

Please confirm your Email Address* This field is required.Please ensure you use the same as given in the appointment booking.

example@example.com

Confirm Email

3

And lastly, please confirm your Phone Number* This field is required.

Please enter a valid phone number.

4

Please describe your current health and the issues you're hoping to resolve* This field is required.

5

How long have you had these issues and what significant life events happened just prior to them starting?* This field is required.

6

How long have you had these issues?* This field is required.

7

What have you tried in the past and what were your results?* This field is required.

8

Describe your current diet/supplements and lifestyle (including work/relationships)?* This field is required.

9

What would your life be like if you could resolve these challenges?* This field is required.

10

Right now I…* This field is required.

Have financial resources to invest in mastering my mind and body

Have access to the financial resources to invest in mastering my mind and body

Don’t have any financial resources at all and I am going to continue struggling on my own

11

If someone asked me to try meditation to help master my mind and body, I…* This field is required.

Know it’s what any serious person would do to solve these problems

Would be a little unsure, but with a proven system I would do it because I am serious about solving this problem

Would avoid it at all costs because I want to do things with as little effort as possible

12

Do you promise to show up for your scheduled appointment on time and distraction free (with your partner or spouse if you make big decisions about your life together)? Confirm by typing “I will” in the box below.* This field is required.

14

Please let me know how you found out about my work (referral, social media, etc)* This field is required.