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Initial Rapha Body Session - Intake Form
First name
*
Last name
*
Email
*
How committed are you in general about learning small practices to support experiencing life fully in your body right now: 1-10?
*
Why did you choose the # above?
What is it I believe about my body this situation is showing me?
What specific outcome are you currently focused on? Remember: be SPECIFIC. Don't just say "better" - If it was clear and specific and done and stated in the positive/present tense, how would you clearly write your outcome?
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What got in the way of you achieving your outcomes?
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What are the top “symptoms” that usually hold you back from moving forward?
Rate your current Stress level: 1-10
Rate your digestion (bowel movements, reflux, heartburn, gas, bloating) over the last 5 days: 1-10
Rate your current pain level: 1-10
Rate your sleep over the last 5 days: 1-10
Rate your hydration over the last 5 days: 1-10
What supportive body practices are you doing consistently?
What else do you want me to know?
Submit
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