Private Client Application
Once the application is submitted and upon availability + acceptance, we will contact you to schedule a 15min clarity call. This call is *not* for personal medical advice, nor for sales. The purpose of the call is to clarify any outstanding questions you may have. By submitting your application, you agree to the terms of this call.
Sign in to Google to save your progress. Learn more
Email *
Phone Number *
First Name *
Last Name *
Top 3-5 health concerns *
MAIN *specific* goal you want to accomplish over next 6 months (ie: Reduce anxiety to 2/10 severity, with it only occurring 1-2x per month for <2 hours). *
Briefly describe what you've tried so far to relieve or address your concerns (food, lifestyle, home remedies, counseling techniques, supplements, previous practitioners or programs). Please indicate what has brought the most relief. *
Are you currently under the care of a local primary care provider or under a practitioner's care for a specific health concern? *
Are you currently ready to invest in addressing the root causes + taking charge of your health? *
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report

Google Forms