Tell me more…

I would SO appreciate you filling out this form!

Thank you kindly for filling out this survey to be a part of the Small Group 10 Sessions. Your honest responses will assist me in understanding where you’re at and how I can best support you in your journey. This program is specifically for people who are deeply desiring to participate in a Rebirthing Breathwork Journey for healing, but can not afford the full program.

Name

First Name

Last Name

What is your town/city of residence & your timezone?

Why do you want to be a part of this group program?

What are the challenges you face in your life right now?

How do you want to feel about yourself after you finish completing 10 sessions?

How would being a part of a group benefit you?

This program is specifically for people who are deeply desiring to participate in a Rebirthing Breathwork Journey for healing, but can not afford the full program. Please share a little more about your financial situation...

Do you have any of the following?

Bipolar 1 or 2

Schizophrenia

Vertigo

Pregnant

Epilepsy

None of the above.

If you answered yes to any of the above, please describe.

Which time would be better for you?

Are you ready to invest in yourself and in your healing and walk away with a skill?