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1:1 IBS Coaching Application Form
PLEASE NOTE THE PROGRAMME IS ONLINE ONLY
15
Questions
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1
What is your full name?
*
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First Name
Last Name
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2
What is your email address?
*
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example@example.com
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3
Phone Number
*
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Please enter a valid phone number.
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4
How did you hear about The Digestive Health Clinic? e.g. Instagram, Facebook, INDI, Google Search
*
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5
Have you been diagnosed with Irritable Bowel Syndrome (IBS) by a healthcare professional?
*
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Yes
No
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6
Please list any medical conditions you have below.
*
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7
Please list any medications or supplements you are taking below.
*
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8
Describe your symptoms below in as much detail as possible.
*
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9
What goal would you like to achieve from
The IBS Relief Programme
& why is this goal important to you?
*
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10
What have you tried before to reach this goal?
*
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11
On a scale of 1 to 10, how much of a priority is it to achieve this goal?
*
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12
I have a high level of success with my clients and want to work with people who are committed & have their goals as a top priority to them. Please tell me why you think you would be a suitable candidate for
The IBS Relief Programme
?
*
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13
The investment for The IBS Relief Programme is 275 euro per month for 3 months. Are you in a financial position to make this investment?
*
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Yes - getting IBS control is priceless
No - I am unable to invest in my health goals at this time
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14
Is there anything else you would like me to know before submitting your application for coaching?
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15
Please select a date & time for your Application Call:
*
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