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Name
First Name
Last Name
Email
example@example.com
Instagram Handle
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Tell me one thing you love about yourself—
Are you currently experiencing any of the following? Check all that apply—
Bloating
Digestion Issues
Anxiety
Brain Fog
Low Energy
Trouble Sleeping
Hair + Skin Issues
None of the Above
How do you feel on a typical day?
Happy + energized
Calm + Relaxed
Anxious + moody
Drained + Lethargic
Tell me three to five things you could be doing for yourself but you’re not and why—
What statement resonates the most to you—
I work out every day and drink lots of water, but I overindulge on the weekends
I eat super clean but I don’t move my body as much as I would like
I’m constantly dieting/cleansing to lose those last five pounds but they always come back
I don’t eat consistently through the day because I don’t have time
Drive thru/meal delivery is my go to
None of the above
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Are you familiar with the link between our gut health and how it affects our physical + mental health and our skin?
I’m familiar but don’t do much
I’m familiar but I need more resources
Gut health is super important to me
No because it’s overwhelming
Are you currently satisfied with your skin?
Yes
Not really
Could be better
Is inconsistent
Are you experiencing any of these skin issues?
Painful cystic acne
Acne
Oily skin
Dry skin
Super sensitive skin
Fine lines + wrinkles
Signs of Aging
Dull/lacking glow
Uneven skin tone
Dark eye circles
None of the above
Are you familiar with ingredients in wellness + beauty products and how these things affect our overall health?
Yes! I’m an avid label reader
I just started my low-tox lifestyle but feel overwhelmed
I’m familiar but feel like I still need support
I’m familiar but don’t really care
I want to help you in any way I can! How can I best share resources with you? Check all that apply—
Product recs for skin + overall wellness
I need a roadmap on where to start + accountability
Send me samples of things that might help!
I’d love recipes, podcasts and/or articles that could help improve my day to day
Invite me to local/in person workshops to sample and help learn more about low-tox living
All of the above
What areas of your life would you want to improve? Check all that apply
My overall physical health
Being more conscious about what I put in and on my body
Better friendships/a community
More income/financial stability
Mindset/mental health
Being more centered + aligned with myself
Are you open to connecting via phone or zoom for a complimentary 15 min consultation to discuss your survey?
Yes!
Not right now
I focus on full body health, meaning what's on and off your plate. I take many things into accommodation, not just your weight, but things like mental health, body movement and mindfulness. My program is not intended for a "quick-fix' but for a lifestyle change by working with your own bio-individuality to create healthy habits you'll stick with. By clicking "I Consent" you agree and understand these terms.
I consent
By clicking "I Acknowledge", you understand that I am NOT a medical professional, medical practitioner, nutritionist or nurse. I cannot prescribe any medications or advise you to stop taking any prescribed medications. I work with the capability I have under my Integrative Health Coaching certificate and am more than happy to work alongside your other healers to create a full bodied healing plan for you.
I acknowledge
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