Virtual patient application to work with Sarah
Please fill out this preliminary questionnaire regarding your request for an initial consultation via Telehealth. Once this is complete, our office will contact you to conduct a screening call to discuss your answers. Thank you.
Email *
Full Name *
Phone Number *
Who referred you to Sarah? *
What is your motivation for wanting to work with Sarah specifically? *
Do you consider yourself to be an open-minded person? *
Do you have reliable internet access and a web camera? *
Describe how committed you are to changing your health.
Do you have the support of others in your household in regards to improving your health? *
No support
Full support
Do you have access to organic food? *
Are you familiar with muscle testing and applied kinesiology? *
Have you ever had muscle testing performed on you? *
How often do you rely on conventional medicine for your health? *
Rarely
Frequently
Are you open to alternative medicine methods? *
If unsure, please explain your hesitation. *
Understanding that muscle testing is biochemistry and physics based for in-person testing, do you understand the concept of quantum physics for remote testing? *
Healing is a journey and not a quick fix. *
Nutrition programs with us run for a minimum of 6 to 9 months, and more as needed to reach optimum health depending on what health issues you are coming to us with. Are you willing and able to commit to a minimum of six months to improving your health? *
If unsure, what is keeping you from making the changes needed to improve your health? *
Dietary changes and temporary food eliminations are often a part of a nutrition protocol and are necessary for optimum healing. Are you willing and able to implement those changes as our testing deems necessary? *
If unsure, please explain your hesitation to making nutritional changes for healing. *
Submit
Never submit passwords through Google Forms.
reCAPTCHA
This form was created inside of NHIC South Jersey. Report Abuse