Form

First name*

Last name*

Email*

Phone number*

Age*

State/Region*

Where you currently live

How did you hear about Rooted Well Nutrition?*

Briefly list your top 3 health goals.*

Ex: 1. More energy 2. Heal IBS 3. Lose weight

Tell me more! Give me a brief description of your current health and health goals.*

List your top 3 health struggles.*

What have you tried so far to resolve the issues or reach your goals?*

If you could wake up tomorrow with optimal health in all areas of your life, what would that look like?*

Do you believe you can and will reach your goals?*

On a scale of 1-10, how ready are you to make the necessary changes to reach your health?*