Energy & Nervous System Reset Application
Name
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First Name
Last Name
E-mail
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example@example.com
Phone Number
-
Area Code
Phone Number
Where do you live?
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Are you pregnant or breastfeeding currently?
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Yes
No
No, looking to get pregnant soon.
If you have done cleanses, detoxes, worked with other practitioners in the past, what did you do & did you have success with it?
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What kind of health issues are you still having that you need one-on-one help with? What are the top 3 health challenges you're still dealing with?
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Which health challenge do you currently have that would be your biggest priority to focus on & need help with for the next 90 days?
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Gut Health
Brain (memory, focus, brain fog/fatigue, productivity) Health
Autoimmune issues (lupus, RA, MS)
Stress
Spiritual
Emotional regulation
Sleep
Lyme
Toxicity issue-- possibly living or working in mold?
All of the above
Other
On a scale of 1-10, how would you rate your current energy levels on a daily basis? 10 being the highest.
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On a scale of 1-10, how would you rate your current stress levels? 10 being the highest stress possible.
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What's the main cause of your stress?
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On a scale of 1-10, how would you rate the quality of your sleep? 10 being the best.
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Do you have children? If yes, how many and what are their ages?
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Are you currently dealing with any digestive issues? If yes, please describe.
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If you woke up 6 months from now feeling AMAZING, what would be different? What would having more energy allow you to do that you can't do right now?
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Are you currently working with a doctor or other health practitioner for the health issues you're currently having?
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Yes
No
N/A
Would you like more help & direction to assist you in this 3 month health intensive?
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Yes!
No, I want to do it on my own.
On a scale of 1-10, how ready are you to invest time, energy, and resources into transforming your health?
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What might get in the way of you following through on a health protocol? What could be holding you back? (time, money, family responsibilities, skepticism, etc.)
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Do you have support from your spouse/partner/family in prioritizing your health?
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Yes
No
Maybe
Are you willing to make changes to your diet, mindset, lifestyle, and daily habits if needed?
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Yes
No
Do you believe that your body has the ability to heal when given the right support? Do you believe that we are wonderfully & perfectly made by God to heal?
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On a scale from 1-10, how important is faith in God in your approach to health and wellness?
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List any medications you're currently taking.
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List any supplements you're currently taking.
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Are you financially prepared to put your health first & invest in YOU right now? About a 5K investment (includes all labs, supplements & biweekly checkins with me).
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Yes, let's do this!
No, I don't, but I will figure it out.
No, I don't right now. What other options do I have?
ANSWER IF LOCAL: Are you able to invest about 1-1.5 hours almost every week in the office for either Chiropractic, NET, Acupuncture, Consults or Massage or can you only do this every other week?
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What's the ONE thing you want most from working together?
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Why now? What made THIS the moment you decided to apply?
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Is there anything else you'd like me to know about your health journey or why you're applying?
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Submit
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