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Full Name *

Valid Email *

Phone *

I live in Kansas/Missouri *

Yes

How old are you? *

Are you on any medications? If so, what for? *

Considering your past treatments, what would you like to improve or do differently moving forward? *

What are the top health concerns that you would like us to help you overcome? *

What would life be like if you were to overcome your health challenges? *

We will guide you on a healing journey requiring consistent participation. How motivated are you to work on yourself to feel better? *

If Other:

Do you have a supportive spouse, significant other, or friend to support your personal goals? *

Yes

If Other:

What are the characteristics that you value most in a professional partnership? *

In your opinion, what makes you a good fit for our practice? *

Our practice is a cash-only practice and we don't accept any insurance. *

Yes, I understand

No, I am unwilling to pay out of pocket

Do you consider yourself coachable? *

Yes

Are you willing to do what's necessary to reclaim your health? (This may include dietary modifications, functional lab testing, lifestyle and environmental modifications, etc) *

Yes

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