Healing and Health Restoration Application Form

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Email *

Hello, Answer a few questions below so we can get a quick start on your strategy call.

What are the most important health and life goals to you from the list below? Check all that apply.

Reduce burn out and feel more energetic

Lower blood pressure

Get off Medications

Better sleep

Reduce stress and anxiety

Weight Loss

Handle uncertainiy and changes with more calm and clarity

Awaken spontaneous joy within

More time and improved relationshiops with my loved ones

Improve concentration, focus and work performance

Other:

Required

Describe your dream outcome, regarding your health and your life?

Honestly, why haven't you achieved your goals so far? What is holding you back?
*

What other ways have you previously tried, to achieve your health goals? Did they work? *

Describe how your job impacts your health.
*

On a scale of 1-10, (1 being, "I am fine where I am" and 10 being, "I'll do whatever it takes") how serious are you about improving your health and changing your life, forever?
*

Full Name *

Email Address *

Phone number *

Use this link to book a strategy call with me.

https://calendly.com/peakhealthandsuccess/strategy-call

Have you successfully booked a strategy call with me?

Yes

Other:

A copy of your responses will be emailed to the address you provided.

Submit

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