First Name *

Last Name *

Email *

Phone *

Age *

Occupation: *

City *

Postal code *

How long have you felt unwell? *

Please briefly describe the symptoms you are experiencing that have led you to seek our program. *

Was there a trigger event to your illness? If so, what was it? *

What type of support system do you have to help change your diet & habits? *

How committed are you to your health goals? *

At what level are you able to invest in yourself to solve this problem?

What do you desire the most? *

I consent to the collection and processing of my personal health information by Integrated Health Foundation for the purpose of joining the waitlist for the Integrated Health Foundation program. I understand that my data will be handled in accordance with our privacy policy and will not be shared with anyone outside of our organization.