Name * First Name Last Name Age * Email * Timezone * Please include a summary of your health history. You can include a major stressful events, physical or emotional traumas. * Additional Space to answer, if needed Are your pregnant or breastfeeding? * Yes No Other What are your current symptoms and how long have you been experiencing them? * What diagnosis do you have from a medical doctor? * What issues do you suspect you have that have not been formally diagnosed? * What treatments, naturopaths, specialists and other practitioners have you tried? * What results (if any) have you achieved from their advice? * Have you done any functional lab testing? (e.g., Genetics, Organic Acids, DUTCH, GI Map, etc) Please list what and WHEN * What medications and supplements are you taking? * Have you ever been on a Benzodiazepine or SSRI? * Yes No Are you having mental health stress, such as anxiety, moodiness, depression, irritability, trouble sleeping, numbness, ect? If so, Please explain * My healing program starts at $4,000 (not including supplements). Are you prepared to invest in yourself at this level, if you're accepted into the program? Coaching Calls cost extra- they are required if I'm helping you wean off meds * Yes, I have the funds now and am ready! No, I'm not prepared to invest in myself at this time Possibly, but I'd require financial accommodations like payment plans On a scale of 1-5 how committed are you to do what it takes to heal- financially, emotionally, and time-wise? 1 being least committed and 5 being the most 1 2 3 4 5 This program requires lifestyle and dietary changes. Are you willing to shift your habits and try new approaches if they are part of your healing journey? * Yes, I'm ready to make all of the changes! No, I'm not interested in making any changes to my diet or lifestyle Maybe, but there are some things I'm unwilling to change (e.g., diet) Why do you want to work with me specifically? What about my approach speaks to you? * What does success look like for you on this journey? How would your life be different 12 months from now? * Do you have any questions? Thank you! We will reach out to you via email soon. Please check spam! Let’s work together.Interested in working together? Fill out the application below and we will be in touch shortly! We can't wait to hear from you!
