Print this page out and answer the questions to receive the discount.
Name:
Challenge:
How long have you had this challenge?
Times per day it affects you:
Ways this problem affects you:
What changes do you anticipate in yourself from the session?:
What methods have you used before to overcome this situation?
Have you read the FAQ page? Please initial here if you have.____
On a seperate sheet of unlined paper, please describe in detail a future scene of yourself without the problem.
