Excited to Get to Know YOU Better!
Completing this form will allow us to empower you toward a more healthful life!
Name
*
First Name
Last Name
Email
*
example@example.com
Best Phone to Reach you Regarding Your Answers
*
Please enter a valid phone number.
What is your PRIMARY health goal?
*
Regulate appetite and reduce cravings
Gut health
Balance hormones
Manage stress levels, daily anxiousness and overwhelm/better mood
More energy
Increased mobility, less pain
Other
What stands in your way from achieving your goal?
*
Diet
Stress
Giving up too soon
Working out
Hormones/energy
Pain
Other
How high are your stress levels?
*
1
2
3
4
5
6
7
8
9
10
no worries-----------------------------------------------------------stressed out
How many hours are you sleeping at night
Less than 4
5-6
7-8
Takes me hours to fall asleep
I toss and turn or am awake up at night
Do you have trouble staying hydrated?
No, I drink tons of water
Sometimes, I should probably drink more
Always, constant struggle
Have you ever tried CBD?
Please Select
Yes, and loved
Yes, did not work
Yes, but I would love better coaching
Not yet, Help me get started please!
What is CBD?
Have you ever tried Mushrooms for wellness?
Please Select
Yes, and loved
Yes, did not work
Yes, but I would love better coaching
Not yet, Help me get started please!
What is CBD?
Are you taking any medications for:
Diabetes/weight loss
Thyroid
Blood Pressure
Mood
High Cholesterol
Blood thinners/Anticoagulants
No Meds
Other
Indicate the TOP health item you would like to seek support on and the average number of YEARS you have struggled with the issue.
ex. poor sleep, 25 years,,, or pain left leg, 10 years
Please use this space to share details or expand on any answers regarding your health, CBD or mushroom experience, or any pet issues (yes, we service pets as well).
Your Age (or the age of the person of inquiry)
*
12 or under
12-17
18-25
26-35
36-45
46-55
56-65
66-75
76 or over
How did you connect with us? USE DROPDOWN
*
Please Select
Healing Trauma Center Referral
Doctors office Referral
Met Holly
Met Michele
Met Dawn
Met Rhiannon
Met Shannyn
Met Marilou
Met Jackie
Met Lynne
Met Claudia
Met Heather
Met Rachael
Met Sarah
Met Rena
Met Erin & Tabitha
Met Sherry
Met Other Team Partner
Energy Lounge
Referral
Business card
In person seminar/vendor event/health fair
Online seminar/health talk/opportunity event
Facebook post/reel
Instagram post/reel
LinkedIN
If Referred, by who?
How ready are you to up level your health and wellness?
I have never been more ready!
I want to but know I need support
I am scared, not sure if I am ready just yet
Submit
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