Apply to work with Susie

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Thank you for applying for a free 15 minute consultation. I look forward to receiving your answers! Best wishes, Susie

Email *

Name *

Email Address *

I would love to know where you are located. If you live within the UK, which country do you live in? Which city or town do you currently live in? *

How did you find me or who referred you? *

What are your main goals for seeking health coaching? *

Support with a specific chronic health condition (eg Crohns, hypertension, diabetes, hormone imbalance)

Lose some weight, increase energy or just a general sense of "I am not feeling as good as I could".

I have been chronically ill for a long time and no one has been able to help me feel better.

I was referred by another practitioner (please state who)

Other:

Do you have any know health, medical condition or diagnosis that I should know about in helping you to find the best care? If so, please explain. *

What have you tried so far to address your goal (diet, testing, modalities) *

Not much, just getting started.

Tried a few things but got overwhelmed by all the information out there.

I have been to more than 3 practitioners to figure this out and understanding or relief is still a mystery.

I have completed other functional nutritional detoxes or cleanses and I am interested in delving deeper into my health concerns.

Other:

Which of the following items are currently in your diet in any amount (select all that apply): *

Sweet fizzy drinks like coke or pepsi

Refined sugar

Alcohol

Fast food

Snack foods like pretzels and crisps

Chocolate, cookies, sweets

Gluten (wheat, rye, barley)

Dairy (milk, cheese, yoghurt)

Coffee

Other:

Required

What percentage of your meals are currently home cooked? *

Less than 25%

>25-50%

>50-70%

>70-100%

Other:

Do you have any specific questions or advice you would like to ask me? *

Send me a copy of my responses.

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