Welcome to Renew & Restore Reset!

Please fill out this short form:

Thank you for taking the time to fill out the following questions. Please submit the completed form at least 24 hours prior to the program begins.

How exciting! You’re taking the first step on your journey to achieve your goals! I look forward to meeting you!

All your information will be kept confidential. An invoice with a payment link will be emailed to you. Payment reserves your space in the group.

Name

First Name

Last Name

Phone

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1. What is your main health concern?

2. What have you done in the past to work on this health condition? (include both alternative and traditional modalities.)

3. What has proven effective?

4. What is your current diet like? Please be specific; list breakfast, lunch, dinner, and snacks, as well as the times you eat.

5. Are you taking any supplements? Please list what you take and what it is for.

6. What would you like your health to be 30 days from now? How about 90 days from now? How would you feel if you got this result?

7. What obstacles, challenges, and struggles do you come up with regarding diet/lifestyle?

8. What do you hope to get out of our time together?

9. What are 5 things you LOVE about your life?

Is there anything else you'd like to tell me about yourself?