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Questionnaire

Fill out this consultation request form to share a little about yourself.

First Name *

Last Name *

Phone *

Email *

Occupation *

State *

Please tell me where you are in your healing journey. *

I am at the very beginning of my healing journey.

I've already done some healing work.

I've done a lot of healing work, but I'm ready to explore more.

What are you struggling with the most? (Choose up to 3) *

Nervous system dysregulation

Irritability with kids/family

Anexiety/Depression

Panic

Worry/fear

Betrayal

Unforgiveness

Anger

Shame

Boundaries

Grief

Codependence

Stress/overwhelm

Fatigue/exhaustion

Chronic pain

Sleep disturbances/insomnia

Hormone imbalance

Gut issues

Skin issues

Other physical symptoms

Other

In as much detail as possible, please describe what you hope to gain from the MENDS Healing program. *

What is your biggest obstacle in achieving your health goals? *

How committed are you to your healing? *

1 (not very committed)

5 (extremely committed)

Who makes the decisions about your health? *

Me, alone

Me and another person (spouse, parent, etc.)

Another person

How did you hear about me? *

Because of the utmost care and consideration to your individuality and the personalized 1:1 care and attention I give to my clients, working with me is a 4-figure investment, for a minimum of 16 weeks. This is not a quick fix because we are working on sustainable lifestyle changes to last your whole life in order to achieve the results you are wanting. Should this be a good fit, are you willing and able to make a financial and time investment into your health? This question is required.* *

Yes, absolutely!

Definitely not.

Anything else you'd like me to know?

Guiding women to holistic wellness through faith-integrated functional medicine.