Coaching Application
With Elevaré Wellness
Are you looking for alternative solutions to your health condition?
Yes
No
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Which of these describes why you are looking for alternative help? Mark all that apply.
I've been to doctors and they can't find a diagnoses.
Doctor's have told me there is no help but medication or surgery for my diagnoses.
I have been told I have Lyme, Mold, Hepatitis, Parasites or some other autoimmune or incurable infectious disease.
I want to enjoy eating again without pain, acid reflux, indigestion or bloating.
I want to consistently have less pain in my joints, muscles and nerves.
I want to regain the strength and energy I lost.
I want to age with more ease and grace then I have been.
I want to learn more about building a healthy lifestyle for me and my family.
Other
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Regarding the statements you selected in the last question, how long have you been wanting to improve these?
6 mo.s
1 yr
5 yrs
longer that 5 yrs
It varies depending on which condition I'm talking about.
Other
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How health conscious would you say you live right now?
How to eat healthy is to overwhelming
1
2
3
4
5
6
7
8
9
I consider myself good with healthy eating.
10
1 is How to eat healthy is to overwhelming, 10 is I consider myself good with healthy eating.
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Are you familiar with any of these terms?
Infectious Diseases
Insulin Resistance
Auto Immune Disorder
Leaky Gut
Harmonic frequencies Related to Health
Mindset Training
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What health challenges are you currently facing?
0/500
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What strategies or actions have you tried so far in order to address your health concerns?
Family Practitioner
Typical Blood work-ups
Special Diets
Chiropractic Care
Different Alternative Modalities
Other
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Which of these can you relate to? Choose any that apply.
I haven't felt like myself in years.
I wake up tired and have to take a nap to get through the day.
I don't have the energy I used to and I don't buy that it's gone because I'm aging.
I've been through lots of tests and everything comes back normal.
I've learned that my bowels don't work like other peoples but the doctor says it's normal.
My stomach hurts everytime I eat but the doctor can't find anything wrong.
The doctor tells me I have an autoimmune disorder that I just have to live with but I've heard other people say differently.
I've hear lots of hype about "healthy" but I don't know where to start.
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What would you say is your current energy level most days?
I never have energy
1
2
3
4
5
6
7
8
9
Occasionally I have a low energy day
10
1 is I never have energy, 10 is Occasionally I have a low energy day
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Is there anything that has not been addressed that seriously impedes your ability to achieve your ideal health and energy goals?
0/500
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Name one thing you feel you do really well as it relates to your health.
0/100
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What is the ideal health scenario you want to achieve?
0/500
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What else in your life is impacted by the state of your health?
0/500
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How motivated are you to gain confidence and momentum toward regaining your ideal health and energy levels?
Not Very--I feel to tired to try anything.
Somewhat--I'm curious, but cautious of trying new things as some haven't worked for me in the past.
Very motivated--as long as it makes sense for me, I'm in!
Very motivated--and I'm nervous how to incorporate what I learn with my family.
Extremely--I'm ready for help ASAP!!
Additional thoughts
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How do you prioritize what needs to be done when you have multiple tasks needing done?
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Can you share an example of a time when you had to change your perspective based on new information or feedback? How did you adapt?
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If this program works out to be a good fit for both of us, what has you the most excited to start this journey to better health and more energy?
1/500
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Name
*
First Name
Last Name
Age
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Email
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example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
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