Consultation Form
My mission is to help you nourish your mind and body and help you discover the harmony of your health. Please let me know some basic information about yourself, what brings you here, and what ways you would like for me to help elevate your life.
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First and Last Name *
Today's Date *
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Your Birth Date *
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Gender
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Email *
Phone Number
Preferred Contact Method *
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Do you prefer a meeting via phone call or video call? *
What are your goals? *
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If "Other" was selected above, please specify below.
How would you like your habits, health, eating, and/or your body to be different? Please specify. *
Which 3 health goals are most important/urgent for you to achieve? *
What type of services do you think would best fit your goals?
On a scale from 1-10, how ready are you to improve your behaviors and habits? *
Not ready
I can't wait to improve and be the best I can be
On a scale from 1-10, how WILLING are you to improve your behaviors and habits?
Not willing
Totally willing
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Appointments Available *
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