Make the changes you need. New Client Discovery LET’S SEE IF YOU QUALIFY . . . Full Name(Required) First Last Gender Email(Required) PhoneHow did you hear about Rapid Life Therapy?:Select oneGoogleSocial MediaMarisa Peer WebsiteReferralOtherIf you selected 'Referral' or 'Other' please elaborate. Please select the one main issue you wish to resolve:(Required) Confidence Anxiety Career Pain Control Eating Disorders Fears Public Speaking Other Are you currently having any type of therapy? If yes, please list.:(Required) Yes No Please list the type of therapy you are currently having:Are you currently taking any medication(s)? If yes, please list.:(Required) Yes No Please list the type of medications you are taking:Describe the problem and how it is affecting you. Shushan will use this information to prepare for the call.:(Required)What does your life look like without the problem?: If there is one thing that the session could give you, what would that be?:(Required) Are you ready to put yourself first and invest in your transformation?: Yes No Are you ready to do the inner and outer work that’s necessary?: Yes No Do we have your permission to add your email to our contact list? Yes No You deserve the freedom you'll find.
