Functional Testing & Coaching Packages | Getting Started Questionnaire
Share your health goals with us and we will match you with the right coach and service for you. Please complete all questions honestly. This information is confidential and only read by members of my amazing team. I will review your questionnaire and we will contact you via email regarding next steps - Jenn XO
testing-package-applicant
Jenn Pike
Full Name
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First Name
Last Name
Email Address
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example@example.com
Phone Number OR Whats App Number OR Instagram Handle - I love sending personal voice notes - not from bots. Humans only :)
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What is your primary struggle right now in terms of symptoms, health concerns, or life impact? (Please be as detailed as possible — share what has led you to reach out for support now.)
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Which package or test are you most interested in at this time?
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Stool Testing
Dutch Hormone Testing
HTMA Testing
A combination
I just want 1:1 coaching with a qualified practitioner, I already have the test results
Other
Who have you worked with previously? (Check all that apply.)
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Naturopathic Doctor
Nutritionist
Dietician
Functional Medicine Doctor
Personal Trainer
Chinese Medicine Practitioner
Other
What programs, protocols, or treatment plans have you tried in the past and what was your experience?
What type of functional testing have you had done? (Examples: DUTCH, GI-MAP or other Stool testing, full blood work, HTMA, hormone panels, thyroid testing, food sensitivity testing, etc.)
Are you prepared to commit to several months of working together, understanding that packages start at $1,197 for that period with payment options available.
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Yes
No
Do you understand that working with us means you are an active participant in your healing? We cannot “fix” you — our role is to guide and support you in implementing the necessary changes in your lifestyle, nutrition, and self-care. I can promise to educate and empower you, explain your situation better than anyone else up to this point has, but I cannot do the work for you.
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Yes
No
Do you understand that our practice is 100% virtual through the Practice Better platform, and all communication will happen there?
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Yes
No
Do you understand that we do not offer refunds for any services?
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Yes
No
Please list any diagnosed or suspected conditions you have experienced. (Examples: autoimmune conditions, endometriosis, PCOS, thyroid issues, Hashimoto’s, eczema, psoriasis, anxiety, depression, etc.)
Is there anything else you would like us to know about you before we review your application?
Submit Application
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