Discovery Call Questionnaire

Thank you for scheduling your appointment. I am excited to speak with you! We get lots of applications so we only work with clients who are committed and serious about their health and those who are willing and capable of taking the next steps required to optimize their health.

Please enable JavaScript in your browser to complete this form.

Name

Layout

Please supply your zip code

Please list the referral name below (if applicable)

Phone

How did you hear about my services? (choose one)

Layout

What top 3 medical struggles are you seeking help for?

Functional Medicine treatment plans require consistent participation. How motivated are you to work hard on yourself to feel better?

This is a high tech, high touch medical practice. People must be comfortable using computers. Please check all that apply for you: (check all that apply)

I check email regularly
I use social media
I have enrolled in an online course before
I have been in a Zoom meeting
I do not use computers often and I prefer not to

Layout

I have the financial resources available to make an investment in my health (up to $3,500.00 for the first 6 months, pricing is 297 a month)

Are you the final decision maker, in regards to your health and finances? If you need someone else to make the decision with you (ie: spouse, parent), please have them on the call with you.