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First name
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Last name
*
Phone number
*
Email
*
State/Region
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As in where you
currently
live
Gender
How did you hear about me? If someone referred you let me know who :)
Please list (in order of importance) what your top 3 health goals are over the next 6-12 months. What have been your barriers to reaching these goals? Please be as specific as possible.
Example 1. Digestive issues 2. Weight gain 3. Fatigue
How are these health issues negatively impacting your life right now?
How much money do you think you have spent on your health issues over the last year? (copays, supplements, missed days at work, medications, other programs).
How much time do you currently spend on your health issues? (appointments, researching, stressing etc.)
On a scale of 1–10, how ready are you to commit to improving your health and well-being right now?
1 (Not important)
2
3
4
5
6
7
8
9
10 (Extremely important)
Imagine... How will life change if you've reached your goal(s) in the next 90 days? 6 months? 12 months? Get specific!
Imagine 5 years from now. What life would be like if you DON'T reach your health goals soon?
Do you have either of the following health insurances?
Anthem
Cencal
No
My packages are a 4 figure investment. At this time are you ready to make that financial investment in your healing process/nutrition goals?
Yes
No
Unsure
Is there another person who must be included in the decision to invest in health consulting?
If yes, please list their relationship to you
Would you prefer a phone call or video call for this session?
Phone
Video
Would you like to be added to the Haley G RD email list?
Yes Please
No Thanks
Already on it :)
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