Name *

First Name

Last Name

Phone *

Country

(###)

###

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What program are you interested in? *

Seek ($555)

Awaken ($1,555)-Includes Tachyon Chamber

Transform ($2,222)-Includes Gift

Quantum Leap ($3,111)-Includes Tachyon Chamber +Gift

Stress Level *

How would you describe your stress level? (0: No Stress, 10: Very Stressed)

1 No stress

2 A little stressed

3 Manageable stress

4 Stress impacts my everyday life

5 Stress is taking over my life

6 I choose to not do things because of stress

7 I am very drained from Stress

8 I find it very difficult to manage my life due to stress

9 I cannot manage everyday life due to stress

10 Stress is all consuming