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1. What is your biggest health challenge or what are you most looking to change? e.g. low energy, digestive complaint(s) (please be specific), weight issues (overweight/underweight) etc.?*

2. How long have you been experiencing these challenges?*

3. What do you feel is the reason for limited-to-no success with other methods you have tried? (select the main reason)*

a) Nobody has been able to help me correctly identify all the root causes of my health/weight challenges
b) The methods I have tried have only addressed aspects/parts of my symptoms/condition(s)
c) Poor client-practitioner relationship(s)
d) Life stressors have greatly inhibited my ability to heal/change
e) I don’t know what I need to do in order to heal/change
f) I know what I need to do but I just don't do it!
g) I've never tried to make any changes before
h) Other

If "Other" in 3. please supply more information

4. If I could wave a magic wand what would your health/weight/life look like? In 3 months? 6 months?*

5. On a scale of 1-10 (1 - “I’m not willing to make changes” / 10 - “I’m ready to do anything to change things”) how willing are you to make changes, even some that may feel a little uncomfortable, in order to reach your goals?*

6. Why would you like to work with me? 🙂*

7. Anything else you think I should know before we speak?*

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