MIND-BODY Medicine Assessment Form

First Name *

Last Name *

Email *

Phone *

Date of birth *

State *

Country *

What are you hoping to gain from this session? *

Are you ready to make a MASSIVE TRANSFORMATION in your life?) Scale 1-10 (10 being highest) *

Are you willing to commit to listen to your Custom Harmonics 2-3x per day? (It's only a 3 minute audio now!) *

Yes

Are you taking any supplements? If so, what are they and want are they used for? *

My biggest source(s) of stress, anxiety or depression are: *

I would rate my current stress/anxiety on a scale of 1-10 (10 being high) *

Please send me a 12 second recording of your voice. It’s best to start with “I am (state your first and last name)”, then Just talk about anything that comes easy for you work, hobbies, families…. The weather.. what it’s like this time of year where you live… anything really. After you say your name, you can even start counting to 15.

When you do the voice clip, be sure to be in a quiet place and speak without pausing.

The AO Scan device will record over 2000 Frequencies in your voice and just 10 seconds. it picks up the emotional imbalances and how it is affecting the physical parts of your body.

It also does a mini vitals scan and will detect any bacteria/ viruses/ parasites / deficiency in minerals or vitamins it found in your body.

Where did you send 10 Second audio clip? *

FB Messenger

IG Messenger

Voice Mail

I agree to terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from the business.