HORMONE HARMONY COURSE APPLICATION

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HORMONE HARMONY COURSE APPLICATION

Dr. Mandy Patterson's Hormone Harmony Course

Application to Join

Email *

First Name *

Last Name *

Phone Number *

Which of these hormone-related issues are you struggling with? *

PCOS

Endometriosis

PMS or PMDD

Thyroid Health (Hypo/hyperthyroidism, Hashimoto's, etc)

Fertility

Other:

Required

Is this the first time you'll be working with a Functional Naturopath and/or Health Coach?
*

Yes

Other:

Required

Tell me about your hormonal health journey up to this point:—What have you tried? What has worked? What has not worked? What supplements or medication have you/are you taking? Have you worked with anyone, etc.?
*

Before you join the course, we want to make sure this is the right program for you, specifically. On a scale from 1-10, mark how much the following statements resonate with you.

I am motivated to make the changes necessary in supporting my body for optimal hormonal wellness.
*

Not Motivated

Very Motivated

I'm ready to optimize my nutrition, sleep, movement, and mindfulness practices to better live in tune with my body.
*

Not Ready

Very Ready

I want root-cause solutions for long-term healing, not band-aids or chemical cover-ups.
*

Don't Want

Really Want

I'm inspired to use the educational resources provided in this course to be my own best health advocate.
*

Not Inspired

Very Inspired

I'm interested in using both leading-edge science and the traditions of whole-body healing to reclaim my health.
*

Not Interested

Very Interested

I identify as a self-starter — with the right tools and education, I know I can make sustainable changes in my life to better my health.
*

That's Not Me

Very Much Me

This course includes a 1:1 call with Dr. Mandy, HTMA and Food Sensitivity testing, plus weekly group calls where you can ask Dr. Mandy questions as you navigate the program. Will you need more, direct guidance and support than is supplied in the Hormone Harmony course? What kind of support are you looking for?
*

How did you find Dr. Mandy?
*

Instagram

Facebook

Google

The Institute for Functional Medicine

Heal.me

The School of Applied Functional Medicine

Practitioner/Doctor/Coach

Client Referral

Returning Client

Friend

Personal Website

Other:

If someone referred you, who can we thank?
*

Anything else Dr. Mandy needs to know?
*

You will be added to our mailing list upon submitting this form. You may unsubscribe at any time.
*

I agree and understand that I may unsubscribe from Dr. Mandy’s list at any time.

Required

Send me a copy of my responses.

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