Let's see if we are a great fit for each other..
Please fill out your information below to help us determine how we can be of service to you
Date of Birth
Cell Phone Number
Please enter a valid phone number.
What e-mail address is best to reach you?
Preferred method of contact?
What are you top 2-3 challenges that you would like us to help you overcome?
Why are these goals important to you?
How would your life change if you didn't have these challenges?
What is preventing you from accomplishing these goals?
What is motivating you to invest your time, money, and energy into solving these problems?
Do you consider yourself coachable?
On a scale of 1-10, how motivated are you to make the necessary diet, lifestyle, and mindset changes toward optimal health?
Do you have a support system at home (spouse, signifcant other, or friend) who is willing to help support you as you work towards your personal goals?
Have you experienced trauma (physical and/or emotional)?
What characteristics do you value most in a professional partnership?
Who else have you worked with?
Functional Medicine Practitioner
Traditional Chinese Medicine
Think about everything that is happening in your life right now (work, school, travel, etc). Why is now a good time to start working on improving your gut health.
What functional lab testing have you had done?
Functional stool testing
Functional micronutrient testing
Genetic or Genomic testing
Heavy metal testing
Organic Acids Testing
When would you like to start the program?
How did you hear about us?
What else would you like us to know about you and your journey to health up until now?
Please note that submitting this for form will help us determine what is the next best step. It does not guarintee an appointment or acceptance into any of the DVA Functional Medicine Programs. We look forward to working with you! :)
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