Getting To Know You Form
Congratulations on taking the first step to explore what’s possible to make positive changes in your health!!
Email address *
Please complete the following for our session:
Name: *
Your answer
Best Contact Number(s): *
Your answer
Occupation: *
Your answer
Employed?: *
Required
Martial Status: *
Your answer
Number of Children: *
Your answer
How did you hear about me?: *
Your answer
Please answer the following 6 simple questions as it relates to your health:
What is your #1 issue regarding your current health situation? *
Your answer
What have you done so far in attempts to alleviate or remedy that issue? (i.e. supplements, detox/fasting, classes, gadgets, etc.) *
Your answer
What were your experiences/results during and after your activity/activities mentioned in question 2? *
Your answer
On a scale of 1-10, how open are you to holistic natural remedies, where 10 is “Very open”, and 1 is “Not open at all”? *
Not open at all
Very open
On a scale of 1-10, how important is it to get your health issue(s) resolved, where 10 is “Needed it done yesterday” and 1 is “not going to make any changes right now”? *
No changes right now
Needed it done yesterday
On a scale of 1-10, how much time can you spend to assist your body with self healing, where 10 is “As much time as it takes” and 1 is “nearly impossible to find time”? *
Impossible to fine time
As much time as it takes
A copy of your responses will be emailed to the address you provided.
Submit
Never submit passwords through Google Forms.
reCAPTCHA
This content is neither created nor endorsed by Google.