Full Name
Email
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Phone
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How does your energy feel on a typical day?
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⚡ I’m wired but tired
🧊 I’m foggy and disconnected
🔥 I burn hot, crash hard
🪫 I’m always running on empty
Which area of your life feels most out of sync?
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🧠 My mind—racing thoughts, worry
💔 My emotions—sensitive, overwhelmed
🦴 My body—aches, stiffness, pain
🌫️ My spirit—I feel lost or low-key numb
How long have you been feeling this way?
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A few weeks
A few months
Over a year
I can’t even remember when I felt “right”
Which statement feels closest to your truth?
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“I’m a high-performer, but my body isn’t keeping up.”
“I give so much to others, I forget myself.”
“I’ve tried everything and still feel off.”
“I’m ready to stop guessing and start healing.”