Thank you for your interest in Heal the Temple, Dr. Heather Rooks' 12-week group functional medicine

program for women who are ready to take a deeper, root cause approach to their health.

Please answer the questions honestly and thoughtfully. This application helps us understand your health concerns and goals so that we can share our recommendations for your best path forward.

First Name

Last Name

Phone *

Email *

Age

What are the top 3 health concerns you are currently struggling with? Please be specific-here are some examples: thyroid, joint pain, fatigue, digestion, blood sugar, hormones, weight, longevity/wellness, mental/emotional health (ADD/ADHD/Brain Fog/Mood) etc. If you're not sure, simply say 'unsure."

Are you currently under the care of a medical provider, or do you have any diagnosed medical conditions we should be aware of?

What, if anything, have you tried in the past and how did it work for you?

Please share what motivated you to apply for HEAL the TEMPLE and what you hope will be different in your health, lifestyle and daily life after completing the program.

Are you willing and able to participate in weekly live/online group calls, doctor and coaching appointments, education and group accountability throughout the 12-week program?

Yes

I'm unsure and have some questions

No, I can not commit at this time

On a scale of 1–10, how comitted are you to taking ownership of your health right now? Please explain your answer: 1 = I am curious but not ready to change 10 = I am fully ready to be guided, supported, and held accountable.

We’re excited to learn more about you and your health goals!

Ready for change? Hit submit and watch for an email or text link to schedule your complimentary Discovery Call with a member of our health coaching team. This is your opportunity to have a personal conversation to help answer your questions, share more about what you can expect from the program and get you started.

Your journey toward greater health and well-being may be just beginning...