Alaskan Essences - Research Programs - New Essence Research Form

Practitioner Discount Research Program
Registration Form

Thank you for your interest in our Practitioner Discount Research Program. To be eligible for an ongoing discount of 15% on all of our products, you must register for the program and agree to be contacted by us for research information in the future.

To register, please fill in and submit the form below. Your discount will go into effect once we have received and approved your application. Note: If you wish to use your discount with our On-line Store, you must create an account first.

	* Required
First Name*	Last Name*

Date*	(mm/dd/yy)

Practice Name	or Company

Address*
City* / State* / Zip*

Country

Phone*
Phone2
Email*

1. Please describe your practice and list all of the modalities you offer.*

2. How are vibrational essences used in your practice? Are they the primary focus of your work, or do you use them to support other modalities?*

3. How long have you been using the Alaskan essences in your practice? Enter 0 if no experience
Flowers* Gems* Environmentals* Sprays* Combos*

4. What other ranges of essences are you using in your practice, and how long have you used them?


5. How do you select and administer essences to your clients?*


6. Do you work with children in your practice??*
	YesNo	If so, for how long?

7. Do you work with animals in your practice?*
	YesNo	If so, for how long?

8. Do you do energy work with environments, such as Space Clearing?*
	YesNo	If so, for how long?

9. What methods do you use to document your work with clients?*


10. On average, how many times do you see a given client?*

11. Please list all formal essence related training you have received, including certification programs given by other essences companies:*


12. Please list any formal training you have received in any other modalities you practice:*


13. Please use this additional space to provide any additional information about yourself and your work with essences:


14. Other Comments:

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