Health and Wellness Interest Form
Share your health goals and preferences to receive personalized support.
Your Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Instagram Handle (optional)
What made you interested in learning more today?
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Health coaching
Natural / lower-toxin products
Weight loss support
More energy
A friend recommended it
Not sure yet — just curious
What are you currently hoping to improve most? (Check all that apply)
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Weight loss
Energy levels
Hormone balance
Gut health
Stress / overwhelm
Creating healthier habits
Reducing toxins in my home
Supporting my family’s health
Other
On a scale of 1–10, how would you rate your current health?
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1 (Needs improvement)
1
2
3
4
5
6
7
8
9
10 (Excellent)
10
1 is 1 (Needs improvement), 10 is 10 (Excellent)
What feels like the biggest struggle right now?
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Which of these sounds most helpful to you right now?
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Personalized health coaching and support
Learning about safer products for my home and family
Both
I’m not sure yet
Have you ever looked into lower-toxin home or personal care products before?
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Yes, I already use some
I’ve been curious but overwhelmed
No, this is new to me
If you found something that truly helped you reach your health goals, what would you prefer?
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Simple product swaps I can start right away
A step-by-step plan with support
A mix of both
If something felt like the right fit for you, what monthly investment would feel comfortable?
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Under $100
$100–$300
$300–$500
$500+
I’m open depending on the value
Anything else you'd like me to know about your health or goals?
How would you like to connect next?
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A quick DM conversation
A short call to talk through options
Just information for now
Submit
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