1:1 Client Application

Hi! Thank you for being here. Please complete this application so I can learn more about your health journey and goals prior to sending over information for you to sign up as a client.

First Name

Last Name

Phone Number

Where do you live? (City/State) Please note: We can only work with clients in the United States

Where did you find us? *

If Other

If you were referred by someone please share their name.

Briefly list (in order of importance to you) your top 3 health concerns or goals.

What have you already tried in order to solve these health issues? Why do you think you haven't been able to reach your health goals on your own?

How do your health issues impact your life? (i.e. is there anything they hold you back from doing or enjoying?)

If you could wave a magic wand and transform your health, what would it look like in 90 days? In 12 months? Get specific!

Do you believe it's possible to reach your goals? *

On a scale of 1-5 (5 being the highest), how ready are you to make changes to your daily eating, exercise, and lifestyle habits in order to reach your goals?

We accept BCBS, Cigna, and United Healthcare insurance in certain states. Do you have insurance coverage that you'd like to use?*