GUT HEALTH APPLICATION FORM

First Name *

Last Name *

Phone *

Email: *

Date of birth *

City *

State *

Occupation *

Hours per week *

What are your health goals right now? *

Gut Health (IBS, bloating, gas, bowels)

Hormone Health (Period pain, missing, heavy ect)

Energy (have more!)

Skin Health (acne, dermatitis, eczema, psoriasis ect)

Heal "diagnosis" (PCOS, endo, thyroid, IBS, autoimmune)

Stress Support (Anxiety, depression, overwhelm)

How important is this goal? *

I want to get started now, make changes & see results!

Its important - but I don't want to start for a couple weeks

I am not sure - I am just looking at different options

It takes a minimum of 6months to make changes to your gut & hormone health - Are you ready to commit to this? *

Yes - I can commit to 6months!

Not at this stage - what are my other options?

What have you tried so far? *

Nothing, I don't know where to start.

Seen GP, Doctors, standard bloods

Seen naturopaths, nutritionists, made some changes

Done functional testing & protocols

The Root Cause Program is a comprehensive hybrid 1:1 and in depth support program, It is a $660 per month Investment - Does this fit within your budget? *

No - I am not ready just yet

Yes - with a payment plan

Yes - I want to heal the root cause!

Testing is a separate cost to the program as it is individualised. Is this an important enough priority that you can allocate $400-$500 towards testing? *

Yes.

No.

Who else do you need to talk to about this before you join? (Please do this prior to the call) *

Can I send you email updates? *

Yes

How did you find me? *

Instagram

Workshop

Google

Facebook

Friend

Other

To get the most out of our call, I need you to understand what a Root Cause Approach & Functional Testing is, otherwise I wont be able to adequately help you in the session. If the resources emailed to you are not watched prior to the call, I may need to reschedule your appointment.

Do you have any other questions?

I confirm that I want to receive content from this company using any contact information I provide.