'Digestion Breakthrough Call' Application Form
Hello!

Thank you very much for your interest in scheduling a free, 45-minute 'Digestion Breakthrough Call' with me.

This application provides me a sense of where you're currently at with your gut health (the specific bowel-based issues you're experiencing), what you've tried, what you're looking to achieve and what's holding currently standing in your way of you achieving it.

Once you have completed the questions below and submitted your form, I will review your responses and get in touch within 1 business day, letting you know whether this call is a well-matched opportunity for you at this time.

Thank you!


Sincerely,

Jessica Pecush, CNE, C.H.N.C., BEd., BPE
Certified Culinary Nutrition Expert
Certified Holistic Nutritional Consultant™
AIP Certified Coach® & Leader In Transformation
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Email *
*The date I'm completing this form is: *
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1. What is your name (FIRST and LAST)? *
2. What is your preferred phone number? *
3. Where are you located? (I work fully online, so location is not a barrier.) *
4. What is your age? *
5. What do you do for work? *
6. On a scale of 1-10, how demanding is your job/career? *
No/Very Little Demand
Very Demanding
7. Which of the following gut/bowel-based issues are you struggling with right now? *
Required
8. Briefly describe what your #1 struggle with these symptoms is right now: *
9. How long has this struggle been going on for? *
10. Please note any known health conditions currently in the picture: *
11. What have you tried in the past to get on top of your health concern(s), including any formal testing? Were you successful with any of your attempts? If not, why not? *
12. Do you current consume a vegetarian or vegan diet? *
13. What is your ultimate health goal right now? *
14. Why it is important for you to solve this gut problem and reach your goal? *
15. Why do you think you've not yet not reached your goal? *
16. How much money do you estimate you've spent on your health journey so far? *
17. On a scale of 1 - 10, with 10 being '100% committed', how committed are you to making positive changes in your health for your long-term well-being should you find a solution that is right for you? *
Not committed at all
100% committed - I'm ALL IN!
18. What is your belief around investing in yourself? *
19. How did you learn about me? *
A copy of your responses will be emailed to the address you provided.
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