What's next for your health, wellness, and personal evolution?
So you're ready for a shift! I'm glad you're taking your health and well-being seriously. I'd like to get a sense of what's going on in your life and what you'd like to see change, which this questionnaire is designed to provide.

Note: If you're a Willamette Valley local and you'd like to receive acupuncture and herbs with me, you need not fill out this form. Just call the office at (541) 757-4868 and we will set you up with an initial series of visits.
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Email *
Full name *
Phone number *
What major shift or breakthrough in your health, happiness, or personal evolution would you like to experience over the next year? *
What's prompting you to want to make this change now? *
Where are you at right now? Please check all that apply: *
How have you tried to solve this problem already? What's been helpful and what hasn't? *
Among the things I help people with are establishing healthy habits. Which of the following are you interested in? *
What could be keeping you from feeling how you want to feel? Again, check all that apply: *
How ready and willing are you to prioritize your health and personal growth at this time? *
Which offering are you most interested in? *
What is it about me or my message or approach  most resonates with you? And how did you hear about my work? *
Is there anything else you'd like me to know?
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