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Mind-Body Workshop

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 Root-Rewire-Restore 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 high level of personalized care and support I provide, working with me 1:1 requires a minimum commitment of 12 weeks. This is not a quick fix, because we focus on deep, sustainable lifestyle changes that lead to lasting transformation, not temporary results or bandaid fixes. Financial investment is $500-1000/month, depending on the level of support you choose. This question is required: If this feels like a good fit, are you willing and able to make both a financial and time investment in your health and healing? *

Yes, absolutely!

Definitely not.

What are you hoping to gain by submitting this form? What kind of support are you looking for? *

Anything else you'd like me to know?

Guiding women to freedom and holistic wellness through faith-integrated mind-body health.