Client Application for Kasey Benavides Nutrition

Today's Date*

First name*

Last name*

Email*

Phone number*

Date of birth*

State/Region*

Where you currently live

How did you hear about us?

Briefly list (in order of importance) your top 3 health goals

Example: 1. Understanding what to eat 2. Bloating 3. Fatigue

Tell us more!

In a few sentences, tell us about your health or health goals

What have you tried already to solve your health concerns?

Why do you think you haven't been able to reach your health goals on your own?

Over the last few years, what do you estimate you've invested in trying to solve this on your own? (consider copays, medications, supplements, programs, time, etc)

What has this problem costed you emotionally and mentally? (e.g. loss of confidence, time, mental energy, etc.)

Working on your health goals can be one of the most rewarding experiences, but it does require an emotional and financial investment. Do you feel ready to put in the work?

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

Is there anything else you would like Kasey to know?

Do you know which program you are interested in?