Let's Get Healthy! Application

Name* This field is required.

First Name

Last Name

Date

How would You describe Yourself?* This field is required.Please select all that apply

I'm developing serious health symptoms.

I experience post-pandemic stress, uncontrollable grief, COVID injuries or other traumas; I can't seem to regain my life's balance.

Almost every day I'm in physical pain

I'm tired of the emotional pain and/or mood swings

I have many allergies, eating has become a necessary burden

I'm experiencing the change of life, and these symptoms are unbearable

I'm constantly comparing myself to others, and the negative self-talk is so challenging.

What Diets / Eating Habits have you Tried or are Presently Trying?* This field is required.Please select all that apply

Keto

Flexitarian

Atkins

Vegan / Vegetarian

Low-Fat Diet

No Carb / Low Carb Diet

Low Sodium Diet

Sugar free Diet

Weight Watchers

Pescatarian

Fasting

Paleo Diet

Blood Type

Gluten Free

None Of The Above

Other

Which Best describes Your Current Relationship with Food* This field is required.Please select One that applies

Healthy, I keep it in it's place

Pretty good, minor discomforts with certain foods

I have a recent diagnosis, and I don't know how to eat to improve my health

Food controls me, I have strong cravings, out of control health and weight.

Other

Which Best describes Your Current Physical Health?* This field is required.Please select One that applies

My body feels amazing (or close to that) pretty much every day. I can get through all my daily activities without pain or fatigue.

My body feels “okay” - nothing specific is wrong, but I am noticing more pain and fatigue than I used to have.

My body feels tired most days; when I wake up, I have to think about how I’m going to budget my energy for the day. I notice myself wishing I could do more in a day.

My body is not well…. I am bedridden a lot of days. I am considered disabled in my current level of abilities.

Other

Rate your Current Satisfaction Level with Your Body at this Exact Moment.* This field is required.Slide the smiley face

Which Best describes Your Current Emotional Health?* This field is required.Please select One that applies

Overall I feel happy day to day. I feel loved by and I have love for those around me. Of course I still have a bad day here and there.

I feel happiness at times, but it comes and goes. I know people love me… but I might not always love myself.

I sometimes have a hard time seeing the good in things. I feel like the deck is stacked against me. Sometimes I feel like giving up.

If I’m being completely honest… I am familiar with depression and despair. I wonder sometimes (or often) what I’m even doing here.

Other

Which Best describes Your Current Mental Health?* This field is required.Please select One that applies

My mind feels clear and sharp. New information is fun and problem-solving is a welcomed challenge

I'm a quick learner, can handle multi-tasking but things have started getting harder for me.

I often struggle with brain fog; Having a hard time finding words, remembering things. Feel overwhelmed at times.

I am tormented by anxiety and I can't organize my thoughts. It can be crippling at times. I am NOT myself, I don't feel in control of my thoughts.

Which Best describes Your Current Spiritual Health?* This field is required.Please select One that applies

I have a clear line of communication with the Creator, I feel fully supported in my life.

I have a spiritual routine that fulfills me, but I don’t necessarily feel fully connected and supported by the Creator.

Honestly this isn’t something I think about a lot; I kind of avoid spiritual conversations, they make me uncomfortable.

I have been traumatized by religion, and I don’t have, or want to have anything to do with spirituality, God, etc...

Other

Either Past, Present or Both, have you ever been treated in a negative way, which left you feeling any of the following? This includes treatment by a person(s), community, an organization or it's representative.* This field is required.Please select all that apply

Abandoned

Betrayed

Bullied

Guilt

Heartache

Humiliated

Overwhelmed

Persecuted

Regret

Rejection

Reproached or Shamed

Slandered

Taken For Granted

None of the Above

Other

In the past, for which of the following reasons did you try Biofeedback Therapy?* This field is required.Please select all that apply

To improve Mood and decrease Depression

To increase Energy and decrease Fatigue

To increase Calmness and decrease Anxiety

To improve Sleep quality

To increase Focus and Attention

Other

I have not tried Biofeedback Therapy yet

How often does it bubble up or come to your mind?* This field is required.Using a scale of 0-10: 0 means it never comes to mind and 10 means daily it comes mind

What were the results of the Biofeedback Therapy you tried in the past?Skip this if you have not tried this therapy

Do you have any questions or concerns about Biofeedback Therapy?* This field is required.

Goals Help Us in 4 Ways, they:

Provide Direction
Encourages Focus
Increases our Productivity
Increases our Motivation

Please tell me a little bit about Your Goals

Where would You like to Be in 6-12 months from Now?* This field is required.Please select all that apply

I want to feel in control of my health and not dependent on a professional.

I want to feel free from food cravings.

I want to be pain free, and wake up and stay energized

I want to be positive about life, and have helpful tools to use when life throws me a curve ball.

I want to overcome this depression and build/rebuild my self-respect.

I want to live a healthy lifestyle.

I want to feel comfortable in my own skin.

What's Holding You Back from Achieving these Goals?* This field is required.Please select all that apply

I'm in my own way. I have a hard time motivating myself and sticking to things... I think because I have a hard time believing it'll work long term.

I can stick to a program, but at a certain point it feels like they stop working for me. My negative thinking gets the best of me.

I am disciplined and I have no problem putting in the work, but I am just not sure what to do for my overall well-being.

I have trouble trusting the process and need something full proof that I can understand myself. Teach me don't just tell me.

I don't have a community or supportive people with similar goals around me

I have a hard time committing and need a heavy element of accountability and support.

Any other Big Obstacles that's Holding You Back from Better Health?* This field is required.

What are You Most Important Health Goals that you Want to Achieve? And please explain why you are open to receiving support at this time.* This field is required.

How Committed are You to Investing In Yourself Today?* This field is required.

5/10 - I don't want to improve my situation that much, I think I'm pretty ok.

7/10 - I am pretty frustrated, but thanks, I'm just window shopping.

9/10 - I want to do this ASAP, but I may have success fears.

10/10 - Sign me up! I'm tired of feeling sick, let's do this!

Best Email* This field is required.

example@example.com

What the Best Phone Number to reach you? (just so we have the right one on file)* This field is required.

Please enter a valid phone number.

Tailored Holistic Health Coaching is an Art

I look forward to seeing

If I can provide what you Need!