Personal Information:

First Name *

Last Name *

Email *

Phone *

City *

State *

1. How would you rate your experience with natural health? *

I'm a novice - I'm skeptical but I've been told I should consider it.

I'm somewhat experienced - I've tried a few things but haven't found anything consistently produced a result.

I'm very experienced - I've invested in myself and my health for a long time now.

2. How did you hear about us? *

Word of mouth

Online search

Social media

Digital ad

Other

3. Do you currently know someone under our care? *

Yes

Health Journey & Goals Assessment:

1. What are your biggest health goals you want to achieve? *

2. What's been your biggest frustration(s) with your health journey thus far? *

3. Which option resonates most with you regarding your financial situation and preferences? *

I have the financial resources to invest into my future health right now and want a TOTAL CUSTOMIZED and CONCIERGE process.

I am MOST interested in your Group or Health Coaching paths.

I do NOT have access to the financial resources to invest into my future right now and this is not a good time for me to get help.

4. What is your commitment to handling your health issues on a scale of 1-10? (1 is low, 10 is totally committed) *

5. What is (are) your biggest concern(s) for your future health? *

6. Are there any other health goals you would like to achieve that were not listed above? Please specify: *

7. Are you willing to invest in a brighter future for yourself? *

Yes

8. Which days of the week work best for you to schedule your appointment? *

I agree to terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from the business.