Client Application Form - Hormone & Metabolic Reset Program

Thank you for taking a few minutes to let me know a bit about you + your health goals so I can determine if you're a good fit for the program. 

Please note that I'm currently only working with clients within Canada (ON, QC, AB and BC) and U.S. (all states except NY, NJ and RI). 

After reviewing your application I will be in touch via e-mail to set up your Initial Consultation.

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Your Name *
Your e-mail address  *
Where are you located?  *

What are your top health goals at this time?

 *
Would you like to lose weight? If so, how much? *

Have you been diagnosed with any medical conditions?

 *
Please list any medications or supplements you're currently taking, including Birth control/IUD *
What challenges have you experienced in meeting your weight and/or health goals? *
What do you think you need to change to meet you weight and/or health goals? *
Do you have a Family Doctor? *
Have you tried anything in the past to help with your health goals? What was helpful and what wasn't?
 *

Do any of the following apply to you?

 *
Required
Please describe what you eat in a typical day, including times you eat 
 *
What do you currently do for exercise/ movement? *
Have you experienced any eating disorders in the past? Please describe. *
What is your main motivation behind wanting to join the Hormone & Metabolic Reset Program?
 *
Have you watched the information video about Hormone & Metabolic Reset Program Program? 
(https://youtu.be/faYt8v6Uwtc)
 *
Are you able to invest $1,497 + applicable taxes into the Hormone & Metabolic Reset Program Program to meet your weight + health goals (includes blood work, custom nutrition plan, one-on-one guidance and support for 16 weeks)?
 *
How did you hear about this program? *
Anything else you'd like me to know?
Submit
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