Journey To Wellness

Let’s Start With You
Name*
Email*
example@example.com
Date*

MonthDayYear
Today's Date
Address*
City*
State*
Two Letter Abbreviation
Zip Code*
Phone Number*
Age *
Height*
Weight*
Goal Weight*
WHERE ARE YOU RIGHT NOW?

And Why It's Time for a Change.
What made you say “I need to do something” about your health?*

Was it the mirror? The scale? Feeling tired all the time? A wake-up call from your doctor?0/330
What’s your biggest frustration when it comes to your health, energy, or weight? *

What have you struggled with? Where do you feel stuck?0/330
What’s something you’ve tried before that didn’t work for you? Why do you think it didn’t work?*

0/330
How do you feel about where your health is at right now? (Pick one)

I’m just getting by, but I know I could be way better.I feel stuck and frustrated-I need real change.I’m overwhelmed and don’t know where to start.I feel decent, but I want to be at my best.Other
Do any of the following apply to you? (Select all that apply)

Gluten intolerance/allergyCeliacHigh Blood PressureThyroidCoumadin (warfarin)Type 1 DiabetesType 2 DiabetesFood allergyGoutGLP-1Medication/Shots(Wegovy/Ozempic/Mounjaro etcOther
WHERE DO YOU WANT TO BE?

And how I get you there.
If I could wave a magic wand and fast forward 3 months from now…what would success look like for you?*
Be specific - how do you want to feel, look, like for you?
What would change in your life if you hit your goal?*
More energy for your kids or grandkids? Confidence in your choices? Feeling strong and in control again?
Why does this matter to you?*
This is big - dig deep! What’s the deeper reason you want this change?
Is there anyone you would like to get healthy with you? If so, who would it be?
What do you do for meals currently? (Eat out, dine in, cook, other)
How did you hear about program?(Were you referred by someone)
Are you a water drinker? If so, how much do you drink in a day?
What else do you drink regularly?
LET'S TALK ABOUT WHAT'S NEXT
The biggest mistake people make? Trying to figure it all out alone. You don't have to. I helped lots of people like you get results - without guessing, without overwhelming, and without wasting time on things that don't work.
NEXT STEPS
✅ Fill this out and hit submit.

✅ I will personally review your form and text you to set up a time.

✅ On the call, well map out a simple, realistic plan that fits YOUR life.
NOTHING CHANGES IF NOTHING CHANGES

HELPING YOU FIND JOY IN THE JOURNEY
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Let’s Start With You