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Cellular Transformation Questionnaire
Dear client,
We want to ensure that Cellular Transformation is a good fit for you. To help with this, please answer the questions below. We will get back to you as soon as possible after receiving your completed questionnaire.
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Email
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Your email
Untitled Title
What is your legal name? What is your preferred name?
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Your answer
What email address can we reach you at?
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Your answer
What is your phone number?
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Your answer
What is your date of birth?
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Your answer
What is your connection to CT? How did you hear about CT / Jennifer Millar?
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Friends or family
Another facilitator of spiritual/therapeutic work
Internet
Social Media
Conscious Community
Other:
If you know someone who has attended a CT workshop with Jennifer before, or an online CT theory course, and has recommended that you do the same, what is their name
?
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Your answer
Why are you interested in working with Jennifer Millar / attending a CT workshop or an Online Theory Course?
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Your answer
Which CT event are you interested in joining?
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Workshop at DIMA Mallorca, Spain
Workshop at House Of Inquiry, Mijas, Spain
Workshop in Karakaya, Turkey
Workshop in Afroz, Greece
Private Online Session with Jennifer
Online Training Course
CT Teaching Program at DIMA
Other:
Have you attended any groups, workshops and/or trainings in the past? Which ones, when and who were the facilitators?
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Your answer
Have you had experience with individual or group therapy? If so, please describe your experience.
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Your answer
Have you experienced any trauma or major impactful events that we should know about? For example: physical, mental or sexual abuse, accidents or severe childhood circumstances, sudden losses. Please specify.
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Your answer
If you are attending an in-person workshop, please list the name, telephone number, and email of your emergency contact:
Your answer
Do you have any physical health issues such as diabetes, asthma, high blood pressure, hepatitis, epilepsy, heart diseases, HIV, MS, etc.? If so, please indicate.
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Your answer
Are you under any psychiatric care or medical supervision of any kind? If so, please specify.
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Yes
No
Other:
Have you ever been admitted into psychiatric care, or treated for any psychiatric illnesses? If so, when? What was the diagnosis?
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Your answer
Are you in need of, or currently taking, any anti-depressants, mood altering drugs, or tranquillisers? If so, please specify.
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Your answer
Are you consuming drugs such as amphetamines, diet pills, narcotics, cocaine, barbiturates, marijuana, heroin, etc.? If so, please give details such as quantities and frequency of consumption.
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Your answer
Do you have any physical handicaps? If so, please specify.
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Your answer
[Women] Are you pregnant? If so, when are you due?
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Your answer
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