Apply to Work With Me

1
What's your name?* This field is required.
First Name
Last Name
2
What's the best email to reach you at?* This field is required.
example@example.com
3
Would you like to be added to my email list to get exclusive access to quantum health tips, freebies, and discounts on my services?* This field is required.
Yes pleaseNo thanks
4
Do you prefer Instagram or Email for me to follow up with you? If Instagram, please drop your IG handle below.* This field is required.
5
What’s your phone number?* This field is required.
Please enter a valid phone number.
6
Please enter your phone number* This field is required.
Please enter a valid phone number.
7
Do you know what level of support you're looking for?* This field is required.
Please Select
Please Select
I'm interested in getting a custom Quantum Fertility Blueprint
I'm interested in a one-time consultation
I'm interested in the Nourish to Flourish program: 4-6 month 1:1 Quantum Fertility Coaching with functional labs
I'm not sure yet
8
What's your occupation? How many hours a week do you work?* This field is required.
9
Have you ever worked with a coach/practitioner in a 1-1 setting or in a group setting? If so, who, what program, and in what capacity?* This field is required.
10
What is your number one goal right now in regards to your health and wellbeing?* This field is required.
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Ok
11
How would you explain your current (or past) efforts to get to your goal?* This field is required.
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12
How much stress are you currently experiencing?* This field is required.
So much stress it's unbearable
A good bit of stress
Not very much stress
No stress at all
13
When is the first time you see the sun/get outside for the day?* This field is required.
14
What is your first beverage of the day?* This field is required.
15
What time is your first meal of the day?* This field is required.
16
How sedentary are you (how much do you sit) during the day?* This field is required.
17
What time do you wake up and go to bed each day?* This field is required.
18
What time do you go to bed each day?* This field is required.
19
What do you struggle with in terms of reaching this goal?* This field is required.
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20
In your opinion, what is stopping you from having the health of your dreams?* This field is required.The more specific you are here, the faster we'll get clarity while identifying the next steps needed to make progress.
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21
In your own words, how are your current habits/lifestyle hurting you/your life?* This field is required.
22
Are you currently seeing a therapist? Have you seen a therapist before? If not, are you open to exploring therapy?* This field is required.
23
Which of the following physical symptoms are you experiencing?* This field is required.Please check all that apply.
Past miscarriage
Infertility
Fatigue
Bloating
Inability to lose weight when dieting
Anxiety
Depression
Constipation
Diarrhea
High stress
Food sensitivities
Heavy periods
Painful periods
Irregular periods
Hair loss or thinning
Acne, eczema, or psoriasis
Headaches
Trouble sleeping
Recurring sinus congestion
Sugar cravings
Brain fog
Other
24
How important is it for you to overcome the obstacles you have in your life in order to make lasting improvements in your health?* This field is required.1- Not Important, 5- Extremely Important
25
Do you have a supportive spouse, significant other, or family/friends who support you in reaching your health goals by understanding and aligning with your personal health mission?* This field is required.If so, who and in what capacity?
26
What is the maximum you're willing to invest in your health? This is a TOTAL amount, not monthly. Please think and be honest.* This field is required.I accept HSAs as a form of payment and I also offer monthly payment plans with zero interest.
$100 - $300
$1,500 - $2,000
As much as I need to
27
Do you have any questions about the personal journey of the practitioner or about the practice?* This field is required.
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