Work with Me Application

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DISCOVERY CALL

Fill out this form to get started. After you submit your form, you’ll be redirected to the next step(s) –You must be at least 18 years old to apply

ABOUT YOU

Your First Name*

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Your Last Name*

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Preferred Email Address*

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Phone Number

What's the BEST number I should call to have our session?

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Where are you located?*

What City/State and Time Zone Are you in? (Please note: Functional labs are only available in the USA and all appointment times are in Eastern Standard Time - EST - UTC−05:00)

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What's your age?*

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What's your height?*

In feet and inches - example: 5ft 4 in or 5'4"

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What's your current weight?*

in pounds, kg or stones (please indicate which you're using)

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How much weight do you want to lose?*

Pick one

up to 15 pounds

15-30 pounds

30+ pounds

I don't care about weight, I want to get healthy, tone up, feel good etc.

I want to gain weight

What are your Goal(s)?*

Pick one

To Lose Fat & Get Fit

To get Healthy, Heal, & Prevent/Reverse Issues

To feel More Energized, Happy, & Positive Mentally

All of the Above

None of the Above

How did you find me?*

YouTube

Facebook

Instagram

Family/Friend

Google Search

What services are you interested in?*

Check all that apply

Nutrition/Meal Planning

Exercise/Workouts

Functional Diagnostic Labs

Supplementation

Coaching & Ongoing Support

All of the Above

I want a one--time session (for recommendations or modifications)

What level of commitment do you want?*

Select all that apply

Personalized & Ongoing Support - 30 to 90 Day commitment

Personalized & Ongoing Support - 90-120+ Day commitment

I'm a current client/active in a Program & want a one--time session (for recommendations / modifications)

I want a one--time session (for recommendations / modifications)

Have you already tried/have any of my Programs?*

List everything you have, have done, or are currently doing.

Reset Cleanse

Metabolic Meal Plans

Mind Right, Body Tight

Workout Program (any or all)

None of the Above

Other

What is your main complaint?*

What's bothering you most that you want addressed? List up to 5 of your main symptoms/complaints that you want to improve.

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How often does it bother you?*

How often do you experience bothersome symptoms? Daily? Weekly? Monthly?

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How long has this been going on?*

Daily? Occasionally? Once in a while? Years? Decades??

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What have you tried so far that hasn’t worked?*

List all workouts, diets, supplements, medications (Rx & OTC), and treatment plans that you've tried

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How does this affect your life or what does it prevent you from doing?*

Job, relationships, enjoying your life?

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Who or what (fear, money, time) may stop you from completing a health rebuilding program? *

Time

Money

Significant other

Fear it Won't Work

Other

What would you expect to achieve working with me?*

Describe your ideal experience

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Since this is an opt-in model of self-care that requires expenses, time, and effort to see change, on a scale of 1-10, how committed are you to doing what's needed to get results?*

If you're not willing to make changes, I won't be able to take you on as a client

Not Committed / won't make changes (0-2)

Barely Committed / I'll think about making changes (3-4)

Kinda Committed / I'm willing to make changes (5-6)

Very Committed / I'm already making lots of changes & will make more to Get Better (7-8)

All In / I'll do whatever it takes to Get / Feel better (9-10)

What is your TOTAL budget?*

What's the total amount you're willing to invest in yourself? Note: This is the total for Appointments with a practitioner, a custom program, supplements, and/or labs, etc.

Less than $300

$300-750

$750-$1000

$1000-$3000

$3000+

Woohoo!

Thanks for filling out the form! This helps make our session(s) much more effective!

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