Form

Client Application
For all 1:1 sessions & consultations

Welcome! I am so happy that you are here, and ready to start taking a step towards better health. I have set up a application system to insure commitment and drive to pursue sustainable changes towards your wellness journey and I want to be able to assist you with making the steps to achieve your goals through this journey of healing.

I am here to help make life easier for you, in all aspects. Whether you need support, guidance, ideas, or navigation in regards to your health and symptoms that you just can't seem to figure out.

Depending on your health, there are 1:1 sessions or a 4-6 month program. We will be working closely together to get to the root of your concerns, and a plan to heal them. Once we address everything including all of your health history there will be a healing protocol personalized just for you.

After you've submitted this application, you will receive an email from me in the next 1-2 business days to discuss more program details, pricing, any other questions you may have regarding me or my practice!

I am so excited to start helping you on this new path! Cheers to a healthier & happier life.

First Name

Last Name

Email*

Phone Number

What are a few of your biggest Health Concerns?

When did these issues arise and How long have these concerns been going on?

How do these concerns affect you on a daily basis?

What have you tried for these issues thus far?

Have you sought out any other

What are your hopes and goals in working with me?

On a scale from 1-10 how committed are you to work on healing naturally? Are you willing to invest in your health mentally, physically, and financially?

If concerns are skin related please upload a few pictures, if comfortable!