Imagine a World
where Everyone Thrives!

Collaborating for the Joy of Healing &

Learning, and Realizing our Dreams

DSA Gift Ticket Provider Membership Survey Questionnaire
Terms of Service

Gift Ticket Provider / Practitioner First Name*

Gift Ticket Provider / Practitioner Last Name*

Referring Member Name*

Phone number*

Email Address*

Notification Preference*

TextEmailText and Email

Name of your Business / Organization

1. Holistic (Healing) Arts Category*

Holistic Arts Practice are any practice that helps one to create space within to unite one's mind, body and spirit, enabling one to choose to express joy and compassion

Yoga & MeditationDanceTai Chi / Gi-GongMartial ArtsEnergy Healing / ReikiAromatherapyCounseling / PsychotherapyMassageAcupunctureMusic Therapy / Sound HealingArts & Music performanceWriting / SpeakingCarpentry / Cooking & BakingGardening & LandscapingCleaning & OrganizingOther / Jobs: (Specify below)

. Other Holistic (Healing) Arts Category

2. Number of Years Teaching or Practicing*

Less than 1 yearBetween 1 - 3Between 3 -5Between 5-7Between 7-10More than 10 years

3. Challenges or Problems your practice addresses*

Need for Creative expressionUniting Mind Body & SpiritHeadache/MigraineInsomniaBack pain (Upper)Back pain (Lower)Shoulder/Neck painAllergyChronic FatigueStressDepressionDigestion problemDiarrhea, ConstipationBreathing problemNervousness/AnxietyHigh blood pressureLow blood pressureMemory lossSinusOther (Specify below)

. Other Challenges or Problems your practice addresses

4. Brief Personal Story

What is your background? What lead you to this practice?

5. Do you have specific client profile that you choose to focus on helping?

6. Are there any client profiles that you choose to avoid in helping?

I declare that the foregoing is true, and accept the terms of service for this application.*

Agree

Date*

Submit

Thank you. Your answers have been submitted successfully. We will be in touch soon! Divine Spark Allies Team