Name

First Name

Last Name

Where are you from? Where are you living right now?

What's your phone number?

Country

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Why did you sign up for this course at this time? (So stoked you did, by the way!)

Tell me where you see the impacts of your developmental trauma show up in your life the most through poor nervous system health...

What do you want to learn the most this winter? (In other words, what are your goals or expectations of the program?)

What time for the weekly session works best for you?

If none of the highlighted times work for you, can you please enter which time would?

We will decide on time as what the majority of the group can attend

Please acknowledge that you have read all the terms and conditions to purchasing a program with me, Emily Aube/ Emily Beatrix Consulting (emilyaube.ca/ emilybeatrix.com) and you are aware that this course is for educational and informational purposes ONLY and not a substitute for medical or psychological care.

Yes