12 Week Journey Application
12 Week journey to Reclaim your health, Rejuvenate your purpose, and Live life again.

Please take this brief survey to help determine if you would be a good candidate for this program before your call with me.
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Email *
Hi, I am Dr. Erin. Welcome to 12 Weeks to Restore Your Health, Rejuvenate Your Purpose and Live Life Again!
What is your full name? *
What is your phone number? *
What is your primary health goal? Check all that apply. *
Required
What is your dream outcome after completing this program? *
What is your goal after the first 12 weeks? *
Where do you see yourself a year from now after committing these new principles to your health journey? *
On a scale of 1 to 10, how serious are you about changing your life forever? *
Not serious at all
I am so serious about this change the this will be my #1 priority
What programs, ideas, or processes have you tried in the past to improve your situation? *
What made you want to fill out this application? *
Thank You for taking the time to invest in your health journey. Your next step is to schedule a call with me. Please use the link below to set up our call to discuss whether this program is right for you.
Schedule your interview here
A copy of your responses will be emailed to the address you provided.
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