To help us get to know you better and set you up for success in the program, please answer the following questions: What time zone are you in? {"type":"text","name":"__generic","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","placeholder":""}
Do you work at this time? Full time Part time Retired Unable {"type":"checkbox","name":"__generic3","width":25,"value":"","size":"Normal","validation":"C1","validationMessage":"Please check at least one item.","options":"Full time\nPart time\nRetired\nUnable"}
Your Age {"type":"text","name":"age","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","placeholder":""}
Are you pregnant? no yes I'm male {"type":"checkbox","name":"__generic4","width":100,"value":"","size":"Normal","validation":"C1","validationMessage":"Please check at least one item.","options":"no\nyes\nI'm male"}
{"type":"checkbox","name":"__generic17","width":100,"value":"","size":"Normal","validation":"C1","validationMessage":"Please check at least one item.","options":"Yes\nNo"} Did you watch the private training "How to Become Your Own Healer" Yes No {"type":"checkbox","name":"__generic20","width":100,"value":"","size":"Normal","validation":"C1","validationMessage":"Please check at least one item.","options":"Yes\nNo"} In MBR, we incorporate a variety of mind-body tools, including meditation. Are you comfortable with this approach? Yes No {"type":"checkbox","name":"__generic21","width":100,"value":"","size":"Normal","validation":"C1","validationMessage":"Please check at least one item.","options":"Yes\nNo"}
Are you on any medications? If yes, which ones? {"type":"textarea","name":"medications","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","height":80,"placeholder":""}
Are you currently in any type of emotional therapy? (Psychologist, counselor, EMDR, etc) Yes No {"type":"checkbox","name":"__generic22","width":100,"value":"","size":"Normal","validation":"C1","validationMessage":"Please check at least one item.","options":"Yes\nNo"}
Are you willing to heal your symptoms without relying on detoxes, strict diets, or excessive supplements (aside from basic vitamins) and are you ready to commit fully to the inner work? (you don't need to be off all your supplements right now)
Yes No Maybe {"type":"checkbox","name":"__generic23","width":33,"value":"","size":"Normal","validation":"C1","validationMessage":"Please check at least one item.","options":"Yes\nNo \nMaybe"}
Do you currently have cancer? Yes No {"type":"checkbox","name":"__generic24","width":100,"value":"","size":"Normal","validation":"C1","validationMessage":"Please check at least one item.","options":"Yes\nNo"}
Between the 2 following times, which time would you be able to attend the weekly group call the most? 11am central 3pm central {"type":"checkbox","name":"__generic2","width":100,"value":"","size":"Normal","validation":"C1","validationMessage":"Please check at least one item.","options":"11am central\n3pm central"}
Thank you answering these questions, we look forward to working with you!
