Name *Street Address *Apartment, suite, etcCityState/ProvinceZIP / Postal CodePhone *Email Address *This is only for your account and will not be sold to others.Age: *How did you hear about us? *What are your main health complaints? *Do you have a pacemaker?NoYesHave you had any organ transplants?NoYesDo you struggle with emotional stressors, such as depression, PTSD, anxiety, constant worry, or OCD? *Please select an optionNoYesPlease explain: *How often do you struggle with worry or anxiety in your daily life? *SelectNeverRarelyWeeklyDailyWhat do you want your ideal health to look like in the next 3-6 months? *Why do you think you have not achieved those goals so far? *On a scale of 1-10, how important is it for you to solve these health problems right now? *Select1 - Not at all important2 - Very minor importance3 - Slightly important4 - Somewhat unimportant5 - Moderately important6 - Fairly important7 - Considerably important8 - Very important9 - Extremely important10 - Of the utmost importanceYour total health is significantly influenced by the state of your mental, emotional, and spiritual well-being. It's not just unhealthy eating, like indulging in fast food, that can affect your health – chronic stress and job dissatisfaction can be just as damaging. Our methods are designed to create deep, lasting changes, with no room for quick, surface-level fixes. How would you rate your readiness, on a scale of 1 to 10, to delve into the mental and emotional facets of your health? *Select1 - Completely unwilling2 - Reluctant3 - Marginally willing4 - Slightly willing5 - Moderately willing6 - Fairly willing7 - Very willing8 - Eager9 - Highly motivated10 - Wholly committedIs there anything else you would like us to know? *SelectNoYesPlease explain: *Would you prefer a phone call or virtual session such as Zoom for your Discovery Session? *SelectPhone callZoom / VirtualSubmitPlease do not fill in this field.
