Request edit access
Waitlist Application
Please fill out all of the questions below and be as detailed as possible.

I am on maternity leave and not currently taking new clients.
You will be contacted in November to schedule a hormone strategy call - looking forward to getting to know you!
Sign in to Google to save your progress. Learn more
Email *
What is your full name? *
What is your phone number? *
What are your main health concerns?
What would IDEAL success with your health look like to you? *
What has been the biggest obstacle in hitting your health goals? *
Why is it important that you solve this health challenge right away? *
What do you usually eat for breakfast? Lunch? Dinner? Snacks? Drinks? *
Have you had any serious illness, hospitalization or injury? *
What excites you the most about working with Leisha? *
Do you have the financial resources to invst in your health right now? (Program costs range from $1,000-$3,000) *
How have you invested in your health so far? What was the result? *
Anything else we should know? *
Do you have a spouse or partner who will be helping you decide if this program is right for you? *
This call is to determine whether or not we are a fit to work together on your health and hormones. Are you ready to commit to start changing your health right away if this program is what you've been looking for? *
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy