Personal Health Counseling & Guidance Pre-Free Discovery Call

Welcome!
Thank you for your interest in a free discovery call with Daria. To ensure that this call will be beneficial for you, please fill out this survey fully and in detail. Your responses will help us understand your needs and determine if this service is the right fit for you.


Sign in to Google to save your progress. Learn more
Email *
Name *
Date of Birth
 *
Age *
Location (City/State/Country)
 *
Email
 *
What are your current health concerns or challenges?
(Check all that apply) *
Required
If you're not fully plant-based, what challenges do you face in transitioning? *
Do you have any known nutritional deficiencies or hormonal imbalances? *
Have you undergone any essential nutrient tests? *
Are you currently taking any supplements or nutritional adjuncts? *
Are you currently taking any supplements or nutritional adjuncts? *
How often do you turn to food for comfort when feeling emotional or stressed? *
How often do you turn to food for comfort when feeling emotional or stressed? *
Required
Do you believe your diet impacts your emotions and mood? *
Required
What are your current struggles with maintaining consistency in healthy eating habits? *
On a scale of 1-10, how confident are you in your ability to embrace and maintain a plant-based lifestyle? *
What are your primary goals for seeking this counseling? *
Required
How ready are you to commit to making changes to your lifestyle? *
Required
Have you previously worked with a health counselor or coach? If YES (please share your experience)
Why do you feel now is the right time to seek this counseling? *
Is there anything else you would like us to know about your journey or expectations?

Thank you for completing this survey!
We will review your responses and get back to you soon to let you know if you qualify for a free discovery call with Daria.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
PrivacyTerms
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms