Your Health Journey Starts Here

Your Health Journey Starts Here

I'm so excited you want to take your health to the next level. Let's start with a free consult. Fill out this survey and I will be in touch with you on starting your health journey. - Kathi White
Name*

First NameLast Name
Email*
example@example.com
Phone Number*

Phone Number
Best Day to Call*

MonthDayYear
Date
Best time to call*

:HourMinutesAM/PM Option
Which age category are you:*

Teen between 15-18 years oldYoung AdultMiddle Aged AdultSenior Adult
What is your WHY? (For example, is there an event or special occasion you are working towards? Fit into your clothes better? Want to clean up your lifestyle?) Be specific!*
What would you like to accomplish with your health journey? (Weight loss, improved sleep, better response to stress, more energy, etc.) *
If you knew failure wasn't an option, where would you like to be in 3 months? Think physically, mentally, emotionally, life goals, etc.*
Do you have any medical conditions or food allergies?*
If you have medical conditions or food allergies, please explain. Include any medications you take for your medical conditions. *

Please complete these questions so I can provide a proper dietary analysis. Based on the information provided, I will be able to match a personalized plan designed just for you. On an average day, do you....

Rows	That's Me	Sort of Me	That's Not Me
Eat Out
Drink at least 8 glasses of water a day
Drink sodas, tea, alcohol, coffee, etc.
Eat several healthy meals a day
Eat a lot of snacks

Are you pregnant or breast-feeding:*

PregnantBreastfeedingNo
Do you exercise or work out 30 minutes a day or more? Exercise is not required but helps me understand where you are in your health.*
How did you find me?*
Are you interested in joining our team of health coaches and building a business of your own? *This can be as part-time or full-time as you'd like. We have everything set up for you to help you be successful! We work for a great company, and I would love to share with you about how it is helping change lives. Would you like to explore the possibilities?*

YesNoMaybe
Thank you so much for filling out the Your Health Journey Starts Here form. Now, just hit Submit and I will be in touch soon. I can't wait to partner with you on achieving your health goals. Dream Big!
Name

First NameLast Name
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