Client Interest Form

Welcome! Thank you for your interest in our Nutritional Therapy programs.  Here at Simply Natural Nourishment, we take a holistic & root cause approach to nutrition and your health. Please fill out the below application so we can get an idea of what is going on with your health and learn more about you and your personal journey. We look forward to getting started and helping you discover the health and wellness you deserve!

Upon review, Team Simply Natural Nourishment will reach-out to you with the step next.  You will receive an email from simplynaturalnourishment@gmail.com with information about our current programs and an invitation to book a Discovery call. This 20-minute call will help us determine if we are a good fit to work together.  Please check your spam folders if you do not see a response in your inbox.

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Email *
Full Name *
Phone Number *
Where are you located?
(City, State)
 *
What is your age? *
Are you married/with a partner?
Do you have a child/children (ages)? *
Which best describes you? *
What is the #1 goal you would like to accomplish in the next 3 months?
 *
What are your other current health challenges that you'd love to overcome? *
How long have you been dealing with these challenges? *
What symptoms are you experiencing from your health problems? 
Check all that apply
 *
Required
How are these symptoms affecting you in your day-to-day life?*
Do they prevent you from performing daily tasks/being present/enjoying life? How do they affect your relationships/job/social life? etc. *
What have you tried to overcome these challenges? Which have worked and which haven't?
(ex. diet/lifestyle changes, doctors, medications, protocols, supplements, labs, strategies or routines, practitioners you've worked with, etc.) *
Have you worked with any doctors, dietitians, nutritional practitioners or integrative medical professionals before? If so, who did you work with & what was your experience like?
 *
What do you feel has been the biggest barrier that has kept you from reaching your goals?
What changes do you know you could/should make that you haven't already made? *
Do you have a diagnosed health/medical condition?
Diagnosed = determined by a medical doctor
 *
If you responded Yes above, please provide details. What is your health condition,  date of diagnosis and is it still current?
Are you currently taking any medications or supplements to treat or manage any of your health concerns? If so please list them below.
 *
Are you ready to try something different, like a holistic approach to address your health concerns? *
If you could imagine your dream health, what does that look like for you? How would it feel? And how is it different from the status of your health right now?
How would you be able to show up in life differently? What would you be able to do that you cannot now? *
What has inspired your interest to work with Katie? What do you hope to get out of the process?*
In order to experience the transformation you desire, you must be emotionally committed and ready to take responsibility for and invest in your health. How committed do you feel in regard to taking all necessary steps to achieve your health goals? 
This can involve: Dietary changes, lifestyle modifications, mindset shifts and supplements
 *
The clients who find success with me and my program are those that are committed to making changes in their lives. Are you willing to commit in investing time and energy for at least 12 weeks to fully investigate, dig deep, and take personal responsibility to re-build your health and experience the health transformation that you desire?
 *
Working with a Practitioner is typically a life changing experience and with that comes an investment... mentally, physically and financially.  After our conversation, if we both feel like it's a match, are you ready and willing to invest in your health & wellbeing?   
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Is there anything else you would like to share with me?
 *
How did you hear about me?
(Instagram, Facebook, Google, Referral - if a friend, let me know who to thank) *
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