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Changed By Fire
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Health Questionnaire
Please fill out the following form to help us understand your condition.
Name
Email or Phone Number
What type of self care do you currently utilize?
Would you be interested in the following services? (Select top 3)
Acupuncture
Burn Scar Massage
EFT/Tapping
Equine Therapy
Essential Oils
Hypnotherapy
Meditation
Reiki
Trauma Recovery
Yoga Therapy
Other
Indicate any issues you would like to address with these alternative healing modalities.
Anxiety
Depression
Lonlieness
Grief
Stress
Anger Management
Pain Management
Insomnia
Self Esteem
Addiction
PTSD
Sensation Discomfort
Self Confidence
Other
Please briefly describe your burn injury.
Initials
Today's Date
I declare that the info I’ve provided is accurate & complete
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