Congrats on booking your consult!

Please complete this short intake to confirm your appointment.

First Name *

Last Name *

Phone *

Email *

What brings you to your consultation? Check all that apply.

Holistic, Medication-Free Weight Loss

Nutrition & Anti-Inflammatory Education

Hormone & Metabolic Health Support

Gut Health & Inflammation Support

Yoga for Menopause & Trauma

Essential Oil Education

Access to Professional Grade Supplements

Interested in hormone or lab testing

Date of birth *

Height *

Current Weight

Goal Weight

Gender *

Current Town/City *

Has a healthcare provider ever recommended weight loss for your health?

What have you tried in the past to support your weight or health? *

Have you ever struggled with your relationship with food or eating? *

Are you currently using any weight loss medications (such as GLP-1 medications like Ozempic, Wegovy, etc.)? *

Do you follow any specific dietary preferences? (i.e. vegan) *

Are you currently moving your body in any consistent way?

What’s bringing you here right now? *

What feels like your biggest challenge when it comes to making changes right now?

What else would you love to feel better in? (energy, sleep, hormones, digestion, etc.) (copy) *

If you were referred, please list their name below.

If this feels aligned for you, how open are you to making changes to support your health? *

Yes! I am ready!

I’m open, but I have some hesitations

I’m just exploring right now

Signature *

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