Hashimoto's Roadmap Application

1
Whom am I connecting with?
First Name
Last Name
2
What are your preferred pronouns?
3
What's the best e-mail address to reach you?
example@example.com
4
Phone Number
Please enter a valid phone number.
5
Have you been diagnosed with Hashimoto's, if so, for how long?
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6
How long have you been experiencing symptoms of Hashimoto's, and what symptoms are you currently experiencing?Provide as much detail as possible, but also know we will dive into this more deeply within the program!
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7
How have you attempted to address these concerns on your own?
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8
What are your goals for this program?(eg understanding your diagnosis, reversing specific symptoms, lifestyle changes etc)
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9
What would you love to solve in next 90 days?Any goals, dreams or desires for your health, wellness and future.
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10
How committed are you to following through with the program to gain a better understanding of your Hashimoto's and begin reversing your symptoms?1 I'm interested, but not sure, 10 I am there every step of the way.
11
Are you open to making changes both through nutrition and lifestyle to support your goals and to reverse your symptoms?
YESNO
12
What type of support have you hired previously to address your Hashimoto's?As you're comfortable, please share what you did any did not like about these experiences.
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Do you have any specific concerns or challenges in relation to participating in a coaching program?
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What questions do you have about me, or my coaching?I'm an open book! :-)
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15
This is not a quick fix, this is an all inclusive solution to begin reversing your symptoms of autoimmunity and Hashimoto's. With that being said, what is your investment comfort level?
I am fully committed to this! I'd like to pay in full ($597)
Give me payment options and I'm in. (3 payments, 4 weeks a part of $325)
This will be a stretch, but I can figure it out if we could talk about other payment arrangements
I'm not sure that I can invest right now.
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