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?
{"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?
{"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"
{"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?
{"type":"checkbox","name":"__generic21","width":100,"value":"","size":"Normal","validation":"C1","validationMessage":"Please check at least one item.","options":"Yes\nNo"}
EVOLVE is not a self-paced, DIY course, you are required to show up daily and do your work for the next 8 months. (no more than an hour a day) Are you committed to this?
{"type":"checkbox","name":"__generic22","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":""}
Important Note:
Our program is designed to help you address the subconscious patterns behind your chronic symptoms. If you are currently taking medications such as antidepressants, anti-anxiety medications, or steroids, the work we do may not be as effective.
If this applies to you, we recommend working with your doctor to safely reduce or transition off these medications before joining — never stop medications on your own.
If you’re currently on these types of medications and decide to join, we may follow up to discuss whether this is the right time for you to begin the program.
Are you currently in any type of emotional therapy? (Psychologist, counselor, EMDR, etc)
{"type":"checkbox","name":"__generic23","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)
{"type":"checkbox","name":"__generic24","width":33,"value":"","size":"Normal","validation":"C1","validationMessage":"Please check at least one item.","options":"Yes\nNo \nMaybe"}
Do you currently have cancer?
{"type":"checkbox","name":"__generic25","width":100,"value":"","size":"Normal","validation":"C1","validationMessage":"Please check at least one item.","options":"Yes\nNo"}
Thank you answering these questions, we look forward to working with you!
