Nurse Yourself Back to Health Application
Welcome! I'm so happy that you decided to apply to my life-changing coaching program. The more information you can provide, the better I will be able to understand your needs, so please be descriptive. This application will take about 10 minutes to complete and there is NO OBLIGATION to purchase the program.

Each year I am able to offer a limited number of FULL and PARTIAL scholarships to clients who are able to demonstrate both an extraordinary commitment to their health, as well as a significant financial need.

Please fill out the form below to apply and I will contact you within 24 hours with a response. You'll receive an e-mail from me with answers to your questions and if I think this program would be a good fit for your needs, you will also have the option to book a FREE 30-Minute Discovery Session with me.

All information you submit is confidential and stored securely, according to my privacy policy.

Sincerely,
Katherine Housh, RN, BSN
Chronic Wellness Nurse

Email address *
Name *
Your answer
Phone number
Your answer
Are you currently employed? *
Have you ever applied for Social Security disability insurance because of your condition? *
Are you a full-time volunteer?
Please select your total household monthly income: *
How much are you willing to budget for health coaching each month? *
How did you learn about health coaching?
Your answer
What is your biggest health concern or challenge right now?
Your answer
What is your biggest obstacle or roadblock to better health right now?
Your answer
What improvements would you like to see in your health three months from now?
Your answer
On a scale of 1 to 10, how committed are you to apply what you learn and follow through over the next three months? *
Not at all committed.
Extremely committed.
Who are your strongest supporters right now? *
Your answer
If we were to work together, what would you hope to gain from the coaching experience?
Your answer
Do you have any other questions or is there anything else that you would like to share?
Your answer
Finally, what is the number one reason you feel that you would be an excellent candidate for this program? *
Your answer
A copy of your responses will be emailed to the address you provided.
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