Please fill out this form for a free 15-30 minute consultation with a Functional Medicine Certified Health Coach
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First and Last Name
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Your answer
Email Address
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Your answer
Phone Number
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Your answer
Time Zone
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Choose
USA: Hawaii (UTC-10:00)
USA: Alaska (UTC-09:00)
US & Canada: Pacific Time (UTC-08:00)
USA: Arizona (UTC-07:00)
US & Canada: Mountain Time (UTC-07:00)
US & Canada: Central Time (UTC-06:00)
US & Canada: Eastern Time (UTC-05:00)
UTC-12:00, Y U.S. Minor Outlying Islands
UTC-11:00, X (American Samoa, International Date Line West, Midwa...
UTC-10:00, W (Cook Islands)
UTC-09:30, V(Marquesas Islands)
UTC-09:00, V (French Polynesia)
UTC-08:00, U (Tijuana)
UTC-07:00, T (Chihuahua, Mazatlan)
UTC-06:00, S (Central American, Guadalajara, Mexico City, Monterrey...
UTC-05:00, R (Bogota, Lima, Quito)
UTC-04:00, Q (Asuncion, Georgetown, La Paz)
UTC-03:30, P (Newfoundland)
UTC-03:00, P (Brasilia, Buenos Aires, Greenland, Montevideo, Santiago...
UTC-02:00, O (Mid-Atlantic)
UTC-01:00, N (Azores, Cape Verde Islands)
UTC+00:00, Z (Casablanca, Dublin, Lisbon, London, Monrovia)
UTC+01:00, A (Amsterdam, Belgrade, Berlin, Brussels, Budapest, Paris...
UTC+02:00, B (Athens, Cairo, Helsinki, Istanbul, Jerusalem, Sofia)
UTC+03:00, C (Baghdad, Kuwait, Minsk, Moscow, Volgograd)
UTC+03:30, C (Tehran)
UTC+04:30, D (Kabul)
UTC+05:00, E (Ekaterinburg, Islamabad, Karachi, Tashkent)
UTC+05:30, E (Chennai, Kolkata, Mumbai, New Delhi, Sri Jayawarden...
UTC+05:45, E* (Kathmandu)
UTC+06:00, F (Almaty, Astana, Dhaka, Nocosibirsk, Urumqi)
UTC+06:30, F (Rangoon)
UTC+07:00, G (Bangkok, Hanoi, Jakarta, Krasnoyarsk)
UTC+08:00, H (Beijing, Chongqing, Hong Kong, Irkutsk, Kuala Lumpu...
UTC+08:30, H (Pyongyang)
UTC+08:45, H (Eucla)
UTC+09:30, I (Adelaide, Darwin)
UTC+10:00, K (Brisbane, Canberra, Guam, Hobart, Magadan, Melbourne...
UTC+10:30, K (Lord Howe Island)
UTC+11:00, L (New Caledonia, Solomon Islands)
UTC+12:00, M (Auckland, Fiji, Kamchatka, Marsall Islands, Wellington)
UTC+12:45, M* (Chatham Islands)
UTC+13:00, M (Nuku'alofa, Samoa, Tokelau Islands)
Gender Identity
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Male
Female
Other/Prefer not to say
How did you hear about Functional Medicine Coaching? If you were referred to us by your practitioner, please state his/her full name.
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Your answer
What do you hope to achieve out of your experience with your health coach? What are some goals that you'd like to work on?
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Your answer
Would you like coaching support in any of the following areas?
Healthy Aging
Allergies, Asthma
Arthritis, RA
Attention Deficit Support
Autism Spectrum Support
Autoimmune Support
Cancer
Cardiovascular Health
Children and Family Support
Cognitive Functioning
Detoxification Support
Environmental Health
Exercise/Movement
Fatigue
Diabetes, Pre-Diabetes, Insulin Resistance
Digestive Health (Food Sensitivies, Sibo)
Emotional Eating
Healthy Cooking, Meal Planning
Women's Health
Infections (Lyme, Candida, etc)
Meditation and Relaxation Training
Men's Health
Mental Health (Anxiety/Depression/Mood)
Mercury and Heavy Metal Toxicity
Migraines and Headaches
Mold Toxicity
Neurodegeneration (MS, Parkinsons)
Pain Management
Postpartum and Pregnancy
Sexual Health
Stress Reduction
Sleep Management/Hygiene
Thyroid, Adrenal and Hormone Health
Weight Management and Weight Loss
I would like support in:
Healthy Aging
Allergies, Asthma
Arthritis, RA
Attention Deficit Support
Autism Spectrum Support
Autoimmune Support
Cancer
Cardiovascular Health
Children and Family Support
Cognitive Functioning
Detoxification Support
Environmental Health
Exercise/Movement
Fatigue
Diabetes, Pre-Diabetes, Insulin Resistance
Digestive Health (Food Sensitivies, Sibo)
Emotional Eating
Healthy Cooking, Meal Planning
Women's Health
Infections (Lyme, Candida, etc)
Meditation and Relaxation Training
Men's Health
Mental Health (Anxiety/Depression/Mood)
Mercury and Heavy Metal Toxicity
Migraines and Headaches
Mold Toxicity
Neurodegeneration (MS, Parkinsons)
Pain Management
Postpartum and Pregnancy
Sexual Health
Stress Reduction
Sleep Management/Hygiene
Thyroid, Adrenal and Hormone Health
Weight Management and Weight Loss
I would like support in:
How would you prefer to be coached? (Mark all that apply)
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In person
Online
Telephone
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How long would you be available per coaching session?
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30 min
45 min
60 min
90+ min
Fees you are willing to pay for a Functional Medicine Certified Health Coach. Please select all that apply.
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$25-$50
$50-$75
$75-$100
Sliding Scale
Required
Is there a particular health coach you would prefer to work with?
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Yes
No
If you answered "yes: to the above question, please list the name of the health coach you would prefer to work with:
Your answer
Primary Language
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English
Spanish
Chinese
Arabic
German
Other
If you seleted "other" for your primary langauge, please specify:
Your answer
Please check the following box to ensure your understanding of partnering with a health coach:
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I understand that I will be working with a health coach and will not be provided with a diagnosis or treatment for any medical or psychiatric conditions.
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