Breakthrough Request Form - Client(#22)
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Breakthrough Request Form - Client
To be filled by the Client
Name
Email
Phone Number
Address
Age
Date of Birth (mm/dd/yyyy)
Gender
Male
Female
1. What do you already know about the unique nature of work that Antano & Harini do?
2. What are your Current challenges/problems?
3. What specifically do you see as an outcome from an Intervention with A&H Excellence Installation Specialists?
4. How would you know when you have achieved the expected results from the intervention? Describe in detail about how you would feel different, think differently and perform differently.
5. Why are these changes important to you? And how will it help you achieve your life dreams and goals?
6. Are you on any Medication currently? (Medical, mental health etc.)
7. Are you currently undergoing any form of treatment (medical, mental health etc.)
8. Any alternate therapies, techniques etc. that you have explored in the past? If yes, mention what you intended to solve with them, and what happened? Also, please mention if any you are still pursuing any of these modalities.
9. If your problems are solved, what would you ideally like to be doing, achieving in life?
10. Any other comments:
Submit
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