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Get Your Life Back Consultation

Please complete and submit this form to request a complementary Get Your Life Back Consultation. These consultations are for people with chronic health conditions (or people with loved ones with chronic health conditions), who would like to become clear on what steps they can take to overcome their (or their loved ones) symptoms naturally and get their lives back.

Filling out this form prior to our appointment will allow us to hit the ground running, and make optimum use of every minute of your consultation time.

Please answer each question in the space below it. If you are not the person with the chronic health condition, please fill out this form as if you were the person with the chronic health condition.

 

What conditions have you been diagnosed with?

What other conditions do you suspect you may also be dealing with?

What are the symptoms you find the most difficult to live with?

Do you take any medications? What are they? What are they for?

What conditions do other people who you are related to, or who live in your household, have?

If you had your vision of your ideal health, what would it look like?

If you had your vision of your ideal health, what would your life look like? How would your life be different than it is now?

How do you imagine it would feel to achieve your vision of your ideal health? List at least 3 words to describe your feelings.

What's holding you back from achieving your vision? What are your biggest obstacles?

On a scale of 0 to 10, (where 10 is "I'll do whatever it takes to feel better," and 0 is "I'm not really very committed") how committed are you to taking the steps you may need to take to improve your health?

If your answer is not a 10, why isn't it a 10?

On a scale of 0 to 10, how cooperative are the people you live with in helping you take the steps you need to take to improve your health?

If your answer is not a 10, why isn't it a 10?

What questions or concerns do you have that you would like discuss in our session together?

What is your time zone?