First Name
Last Name
Email
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Phone
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Where are you located? (State/Country)
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Which Program Are You Interested In?
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The Histamine Recovery Intensive
The Histamine Clarity Protocol
Not Sure
What type of Practitioners have you worked with so far?
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Only regular doctors
Acupuncturist
Herbalist
Holistic/Naturopath (not functional or MD)
MD with Functional Medicine Training
Functional Medicine Practitioner (FMP)
Geneticist
Other
Have you had functional medicine testing? If so, which tests?
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GI Map/Gut Zoomer/ Other Stool Test
Hormone Testing (Blood or DUTCH)
Genetic Testing
Methylation Panel
HTMA/Mineral/Nutrient Test
Mold/Mycotoxin
Others
On a 1-10, 1 being less and 10 being more - how are your histamine issues affecting your quality of life?
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1
2
3
4
5
6
7
8
9
10
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Working with us is an out of pocket expense not covered by insurance. Are you ready to make a financial commitment to solving your current problem?
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Yes, I am tired of feeling this way!
No, not right now.
Tell me in as much detail why you are seeking help from me now?
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Does your spouse/partner/parent support you on this journey?
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Yes
No
N/A
Are you truly ready to make lifestyle changes to see progress? (minor AND major)
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Yes! I am ready!
Maybe - I have struggled in the past
No, I don't really want to put in the work
When are you looking to get started?
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ASAP
Within a few weeks
A month or longer
SUBMIT
