Emotion Code Survey

Fill out this 3 Minute Survey below to provide the information needed to prepare for your Emotion Code Session.

Each evaluation is personally done by me using applied kinesiology, also known as muscle testing, which will reveal your body's needs. Through muscle responses, I will test to identify the emotional frequencies that are related to the issues you're experiencing. 

I look forward to testing for you. Please let me know if you have any questions or concerns.

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First Name:

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Last Name:

If Client is a Minor/Child - Parent/Guardian's First & Last Name:

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Age:

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Gender:

City/State:

Country:

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Have you used essential oils before? 

If yes, what did you use it for and what were the results?

Any questions or concerns, or anything you feel I need to know or take into consideration when testing?

Is there anything else you'd like me to know?

Please identify specific issue #1 (pain, illness, condition, emotional problem, etc):

Please rate issue #1 (1= hardly noticeable - 10= extreme):

Please identify specific issue #2 (pain, illness, condition, emotional problem, etc):

Please rate issue #2 (1= hardly noticeable - 10= extreme):

Please identify specific issue #3 (pain, illness, condition, emotional problem, etc):

Please rate issue #3 (1= hardly noticeable - 10= extreme):

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Upon reviewing your responses from this evaluation, I, Cynthia Gene, will complete a custom report for you. How would you prefer to connect so we can go over your results?

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By submitting this survey, you give Cynthia Gene permission to do an applied Kinesiology by proxy session. If you are submitting for a minor or for an adult who is not capable of deciding or responding for themselves, and are a parent or a guardian, you grant permission for Cynthia Gene to do an applied Kinesiology Session.

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I have read and agree to the DISCLAIMER, TERMS & CONDITIONS

Disclaimer, Terms & Conditions 
The recommendations provided should not be accepted for professional advice or treatment. All recommendations will be presented in good faith. The accuracy, validity, effectiveness, completeness, or usefulness of any recommendation herein cannot be guaranteed. We strongly advise that you seek medical advice from your medical practitioner as appropriate before making any health decisions. The information provided with recommendations is not a substitute for medical care, diagnosis or treatment. Recommendations should not be considered as a replacement for consultation with a health care professional. If you have questions or concerns about your health, please contact your health care provider. Cynthia Gene, The Integrative Wellbeing Coach & Consultant makes no claims regarding healing or recovery from any illness. Any suggestions regarding supplementation of any kind, that you use or ingest any such at your own risk, with the recommendation that you seek the advice of a physician before using any remedy suggested. By submitting this disclaimer, you consent, in the event of a dispute or disagreement, that you understand the contents of this disclaimer and that Cynthia Gene, The Integrative Wellbeing Coach & Consultant accepts no responsibility or liability for both the use of the information provided and information provided with sessions. 

 

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