Are you ready to start feeling better? This is the first step in your journey to better health! Name * First Last Email Address * Phone * Address Field * Address Line 1 * Address Line 2 City * State * Zip Code * This is only for your account... we will not be sending you SPAM mail. Age: * How did you hear about us? * What are your main health complaints? * Do you have a pacemaker? — Select — No Yes Have you had any organ transplants? — Select — No Yes Do you struggle with emotional stressors, such as depression, PTSD, anxiety, constant worry, or OCD? * — Select — No Yes Please explain: * How often do you struggle with worry or anxiety in your daily life? * — Select — Never Rarely Weekly Daily What do you want your ideal health to look like in the next 3-6 months? * Why do you think you have not achieved those goals so far? * On a scale of 1-10, how important is it for you to solve these health problems right now? * — Select — 1 - Not at all important 2 - Very minor importance 3 - Slightly important 4 - Somewhat unimportant 5 - Moderately important 6 - Fairly important 7 - Considerably important 8 - Very important 9 - Extremely important 10 - Of the utmost importance Your total health is significantly influenced by the state of your mental, emotional, and spiritual well-being. It's not just unhealthy eating, like indulging in fast food, that can affect your health – chronic stress and job dissatisfaction can be just as damaging. Our methods are designed to create deep, lasting changes, with no room for quick, surface-level fixes. How would you rate your readiness, on a scale of 1 to 10, to delve into the mental and emotional facets of your health? * — Select — 1 - Completely unwilling 2 - Reluctant 3 - Marginally willing 4 - Slightly willing 5 - Moderately willing 6 - Fairly willing 7 - Very willing 8 - Eager 9 - Highly modivated 10 - Wholly committed Is there anything else you would like us to know? * — Select — Yes No Use this box to give us any extra details: * Would you prefer a phone call or virtual session such as Zoom for your appointment? * — Select — Phone Call Virtual Session (Zoom, etc) Thank you for completing this form! When you click submit, you will be taken to our scheduling page where you can book your free 15-minute session
