Private Coaching Application

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Please complete this brief application to help determine your eligibility and if selected you will get a response within three business days.

Email *

Name *

Phone number *

What are you applying for? *

H.E.R Monthly Membership

A 16-Week Transformation for Women: Clarity, Energy & Weight Loss

Are you able to be available for appointments? *Note(Central Standard Time) *

Monday 11:00 A.M-1:00 P.M

Wednesday 8:30 A.M- 9:30 A.M

Wednesday 11:00 A.M-1:00 P.M

Wednesday 3:30 P.M- 4:00 P.M

Friday 11:00 A.M-1:00 P.M

Briefly describe your symptoms *

What have you already tried to resolve this problem? *

How are these issues holding you back from your life, career, and aspirations? example: your low energy is keeping you from doing things you enjoy or hard to get up and start your day. *

Why is now the right time to address these issues? *

Age *

Are you currently under the care of a physician or healthcare provider? If yes, could you please share briefly why? This information will help me better understand your overall health and any specific needs you may have during our coaching sessions
*

Are you taking any medications? If yes, please feel free to list them along with what they are prescribed for. Your health information is treated with the utmost confidentiality and will only be used to better tailor our coaching sessions to your needs.
*

Do you think friends and family will be supportive of you making changes to improve your health? *

Yes

Eva, if I am selected and decide to work with you, I’ll find a way to invest in myself and my future:

I have the necessary means to invest in my health and future

I have the ability to get the necessary means to invest in my health and future

I have no financial means to invest in my health and future

GDPR agreement

I'd love to send you information about how to recover from burnout & chronic pain, along with especial events & promotions.

Yes, I'd like to receive newsletters, especial health events and promotions by email. STM does not sell or share your information. I understand I may opt out at any time using the unsubscribe link provided in all communications.

No, I do not want to receive any communication.

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Send me a copy of my responses.

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