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Wholistic Health Acceleration

Hello, and welcome to Wholistic Health Acceleration with Rachel & Laura!
We are so excited to welcome you in!

First, let’s get to know you. By letting us know a few quick things about you it will allow us to continue to design and incorporate relevance and learning that appeals to everyone, including YOU!

Please fill out the following information and send it right back and we will be sure to keep your information confidential while keeping your interests in focus as we bring forward new, exciting information with you in mind.

Name *

First

Last

Age

Email *

Address

Occupation

Telephone

Emergency Contact Name

First

Last

Emergency Contact Number

What do you wish to receive from our private group page?

FROM THE LIST BELOW TICK THE AREAS THAT CONCERN YOU

Addictions
Drinking
Smoking
Drugs
Gambling
Compulsive Behaviour
Career Issues
Interview Skills
Nerves
Public Speaking
Concentration
Exams
Memory
Driving Skills
Anxiety
Fears
Stress
Panic Attacks
Guilt
Relaxation
Relationships
Childhood problems
Sexual Problems
Fertility
Eating problems
Food/Diety
Weight Problems
Anorexia
Bulimia
Exercise
Pain
Control
Hearing
Sight/Vision
Mobility
Skin problems
Hair growth
Depression
Confidence
Self-esteem
Motivation
Achieving Goals
Procrastination
Sleep Problems

Group Disclaimer – I understand that if I am epileptic or suffer from psychotic illness it is not generally recommended that I undergo hypnotherapy. I hereby agree that by signing this form that I do not currently suffer from these disorders. I understand that Rachel Farnsworth and Laura Shofroth are not licensed physicians, psychologists or medical practitioners and the information, technique, methods and recommendations by Rachel & Laura are not intended to substitute for diagnosis and care by a qualified physician, nor to encourage the treatment of any illness by persons not recognizably qualified. I release Rachel and Laura from any liability or claims concerning my mental and/or physical well-being by checking this form. I confirm that I have read the above and accept these terms and conditions. *

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Transform With Me
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  - Me Too But Never Again
My Podcast
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About Rachel
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Wholistic Health Acceleration

Hello, and welcome to Wholistic Health Acceleration with Rachel & Laura! We are so excited to welcome you in!

Let's Keep In Touch

Thank you!

Hello, and welcome to Wholistic Health Acceleration with Rachel & Laura!
We are so excited to welcome you in!