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SOURCE CODE Intake Form

Welcome to Dr. Sam & SOURCE CODE

We are so happy you found your way to us, and we can’t wait to support you.
With a background in AI, neuroscience, eastern religion, and psychology, Dr. Sam created a new approach to healing called Source Code, where powerful shifts happen fast. After working with clients for two decades, Dr. Sam discovered there are only 12 negative patterns holding us back in life, which she calls our Coping Styles. When we address these patterns, instead of working with the mind, radical change is possible now.
>>Fill out the form below, and our Source Code concierge Ariel will reach out to you. 
INDIVIDUALS: We’re here to help you dissolve and resolve any old patterns that stand in your way.
HEALERS: We’re here to help you and your clients take a quantum leap.

Are you here for your own healing, or as a guide and healer for others?

Are you here for your own healing, or as a guide and healer for others?
A
B
C

What attracted you to Source Code / Dr. Sam?

What attracted you to Source Code / Dr. Sam?
A
B
C
D

What feels out of alignment in your life now that you’d like to shift?

What do you want for yourself and how do you want to feel?

What experience(s) are you most interested in? (can check several)

What experience(s) are you most interested in? (can check several)

Please share your instagram handle:

Please share your website if it’s relevant:

Income

Income
A
B
C
D

Please share your details and we will reach out to connect.

First name

Last name

Phone number

Email