Wellness Journey Customization Questionnaire
After submitting this form, I will personally email or text you to help you with starting your mind, body, and soul wellness journey. I will match you with products to best support your needs. I am looking forward to working with you on your wellness journey.
Name
*
First Name
Last Name
Gender Identity (to ONLY help with understanding your biological make-up)
Woman
Man
Non-Binary/Gender Non-conforming
Prefer not to say
Have you ever had ovaries/and or a uterus? (This will help us better understand your wellness needs, including hormonal changes like menopause.)
Yes
No
Prefer not to say
Are you currently experiencing or have you experienced perimenopause, menopause, or menopausal symptoms (natural or induced)?
Yes
No
Not sure
What is your age?
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
How did you find me? If a referral, who can I thank?
I am interested in:
Exercise plan
Change in Eating Plan
Guided journaling, meditation, etc.
Natural supplements such as hemp, functional mushrooms, vitamins, etc
Prescribed supplements like peptides, NAD, B12, etc
I am not sure
Other
Who are you seeking the information and products for?
Myself
My kids
My pets
A loved one
What are you seeking help for?
*
I am an emotional roller coaster
I can't focus
Everything hurts
I want to protect myself against germs better
I can't stop yelling at my kids/spouse
My tummy is unhappy
My get up and go got up and went
The scale isn't my friend
My frustration levels are off the charts
Not getting quality shuteye
I am an athlete and need post-workout help
I wish my hair, nails and skin were healthier
I feel like a hot mess all the time
I sweat even when I am sitting on the couch
I am swollen all over
I've got 99 problems and I need a solution for all of them
Other
Please elaborate on the symptoms you're dealing with. Are they acute or chronic? How long have you been dealing with them? What have you tried in the past? Did it work?
Please tell me if you have any diagnoses or health issues, plus what medications and OTC medications, vitamins, & supplements you take.
Do you have any physical or medical issues that will inhibit you from any certain type of exercise?
What type of exercise do you prefer?
I don't like any type of exercise
Low impact
Chair exercises
I like to sweat
Weight lifting
Cardio
HIIT/Crossfit
Are you interested in more of a doctor-led approach with prescription meds and telehealth visits or the more natural approach, or a combo of the two?
Doctor-led approach
Natural approach
A combo of the two
I am not sure
Are you interested in working virtually with a health coach for your eating and exercise plan to have it all done for you (there is a cost associated with this).
Doctor-led approach
Natural approach
A combo of the two
I am not sure
If the scale is not your friend, what have you tried in the past?
Meal prepping
All the diets
Weight lifting
Walking
Medications
Supplements
Insane amounts of protein
Cardio
HIIT Workouts
Crossfit
Other
If you would like to add more detail, please do so. It will help me guide you.
Have you used CBD, functional mushrooms or other plant-based products before? If so, what products did you use? What were your results?
Are you comfortable with the legal trace amount of THC (up to 0.3%)? There are no psychoactive properties (no high). You may wish to avoid if you are routinely drug tested for any reason.
*
Yes, if it could make me feel better
THC Free only please
Either is good for me
Undecided
Are you open to injectables?
*
Yes, if it could make me feel better
I hate needles
Either is good for me
Undecided
Do you have a budget I need to work within? *As a new customer, you are able to get started with 2 full sized products for only $99 (45% off) or 3 full sized products for only $139 (45% off)
*
$60-$80
$80-$110
$110-$160
I'm more concerned with results
Please give me good, better, best product suggestions
Please recommend the single most beneficial product
The new customer bundle sounds perfect
Other
CBD comes in different forms. Tinctures, which need to be held sublingually for 30-60 seconds, edible (jellies/gummies), or topical. Would you have a preference?
*
Tincture
Edible
Topical
No preference
While the effects of the products I recommend are occasionally seen quickly, it's not uncommon for it to take several days or months to fully experience the results. Are you willing to give the products a minimum of 90 days of consistency? And keep me posted on your progress -- I want to help you with dosing every step of the way.
Yes, Absolutely
I'll try, but I have a lot going on.
How would you like your results?
*
Text
Call (15 minute consultation)
Email
If you could earn product credit, discounts and commission by sharing products with your network, would that be something you want to learn about?
*
Yes, I am open for more information
Not for me
Maybe in the future
By marking YES, you understand that this is only personal advice. I am an independent sales representative for the companies in which these products are being recommended. Results may vary. These products are not intended to diagnose, treat, cure, or prevent any diseases. It is always recommended that you speak with your doctor before beginning any supplements.
*
YES
Anything else I should know?
Submit
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