Chakaura by Michele

Chakaura Program Application

Please follow the instructions and fill out the application questionnaire.

Chakaura™ Program Application

Chakaura Centering Bridge the Gap - Manifest Membership

Name(Required)
Address(Required)
MM slash DD slash YYYY
What is your gender at birth?(Required)
What is your work status?(Required)
Example: NLP, Reiki, Energy Healing modalities, Osteopathy, Chiropractic, Numerology, Astrology, Medical license, Yoga, Reflexology, herbalism, etc. please include year of ..
Example do you run a clinic, offer services in any of the above, visit a professional for treatment, and how often a week or month, etc.
Example: Tiktok, Instagram, Pinterest, Facebook, Twitter, LinkIn, etc.

EMERGENCY CONTACT INFORMATION

Emergency Contact #1(Required)
Address(Required)
Emergency Contact #2(Required)
Address(Required)

Agreement

Application Requirements

Recent 2 x 3 approximate colour photo of you, a head shot with no others in view, looking straight to the camera lens, preferably light-colored background: plain wall.(Required)
Accepted file types: jpg, jpeg, png, gif.
Digital copy of either your Driver’s license (both sides) or your passport. (proof of identity)(Required)
Accepted file types: jpg, jpeg, png, gif.

Energetic Health Questionnaire

Are you presently being followed by a health professional?(Required)
Do you feel you are healthy and in good physical condition?(Required)
Do you suffer from nervous system issues (such as depression, panic attacks, adrenal fatigue, chronic fatigue, thyroid imbalance, other?)(Required)
Do you suffer from hypertension, hypotension, asthma, diabetes, epilepsy, allergies?(Required)
Are you taking any medications not previously mentioned?(Required)
Have you suffered any health issues in the last five years?(Required)
Have you ever experienced any of the traumatic situations below? Select all that apply.(Required)
Do you have problems sleeping or with your sleep?(Required)
Do you feel you are healthy mentally or psychologically?(Required)
Do you have problems/issues of an energetic nature? For example, being overly sensitive to other people, feeling under energetic attack at times, overly empathic, or side effects from working in energy or being overly drained by your daily activities.(Required)
Are you trained in other energetic modalities?(Required)
Do you have a relaxation method or a meditative technique, spiritual practice that you use on a regular basis?(Required)
What vaccines did you receive?(Required)
Have you had any Adverse Effects? Select all that apply.(Required)

Our Chakaura Agreement

Please ensure that you have read and understood the following Chakaura™ Advanced Initiate Program Agreement.
I am at least 18 years of age and of legal consent age.(Required)
This electronic signature is legal and binding.
MM slash DD slash YYYY
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