Apply for the Roots to Radiance Autism Nutrition Program

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Parent First Name *

Parent Last Name *

Child's First and Last Name *

Child's Birthday *

YYYY

Parent Phone Number *

Parent Email *

State/Region *

What is your #1 CONCERN for your child’s health/nutrition? *

What is your 2nd BIGGEST CONCERN your child’s health/nutrition? *

Wave your magic wand. How would your life be different if your child’s biggest nutrition struggles disappeared or improved? What would that look like? *

What are you hoping to gain from working with Elisa?
*

Is your child experiencing any of the following? *

Food sensitivities

Diarrhea

Constipation

Bloating and abdominal pain

Poor sleep

Anxiety around food

Poor appetite

Selective eating (eating less than 20-30 foods)

Refusing entire food groups

None of these

Required

How did you hear about Elisa? *

I often recommend lab work in an effort to understand what is going on beneath the surface for your child. The costs of lab work can range from $200-$1700 depending on your specific situation. We will discuss this more on a “Get to know you” call. On a scale of 1-10, how prepared are you to make an investment like this to support your child's nutrition? *

I'm unsure

I'm all in

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