Core Wellness Institute Private Coaching Application
Thanks for completing the following application.  

If you are accepted, you will receive a link to enrollment details.

Participants will then be accepted on a first come, first serve basis.

Also, completing this form does not obligate you to anything.

Thanks and hope to talk to you soon,

Dr. H
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What words describe the feelings you have now about your current state of health? (apathy-happiness-anxiety-sadness–embarrassment-anger-Etc.) Why? *
Please describe how you desire to feel? *
What are the main reasons why you are committed to improving your state of health? *
What specific health issues are affecting your quality of life? *
(Name them in order of importance to you)
What is it about this approach that makes you feel like I can help you? *
What are your top 2 specific health improvement goals over the next 8 weeks? *
What is your level of willingness to make changes in your current lifestyle habits towards health?   (0% = I’ll never change, 100% = I’ll do anything that makes sense to me!) *
I understand this coaching relationship is NOT a doctor / patient relationship and I agree to discuss any exercise or nutrition recommendations with my doctor. *
Can you effectively use Skype or can you learn before we meet?
Can you get up and down off the floor without assistance?
Your Name (First and Last) *
What is your primary email address? *
Your location (and time zone if you know it) *
Best phone # to reach you *
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