Spring Elimination Diet

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The following information helps me to get to know you and understand if the elimination diet will be a good fit for you. If you have any questions, please email me at amy@ladleandlotus.com

Schedule of meetings:

Tuesday, March 21st, 12:30-1:30pm

Wednesday, March 22nd, 12:30-1:30pm

Tuesday, March 28th, 12:30-1:30pm

Tuesday, April 11th, 12:30-1:30pm

Tuesday, April 25th, 12:30-1:30pm

Tuesday, May 9th, 12:30-1:30pm

***All sessions on Zoom***

Name *

Email *

Phone number *

What is the best way to get in touch with you? *

Text

Phone call

Please check any of the conditions or diagnoses that you have:

Irritable Bowel Syndrome

Irritable Bowel Disease

Chrone's Disease

Ulcerative Colitis

Frequent or excessive gas

Bloating

Constipation

Diarrhea

Other:

Have you done an elimination diet before?

Yes

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If you answered yes, please describe the type of elimination diet(s) you did.

Please check any that apply to your eating:

Omnivor

Vegetarian

Vegan

Gluten-free

Dairy-free

Paleo

Keto

Other:

What are your hopes for this elimination diet?

What are some of your concerns or questions about doing an elimination diet?

Any health concerns or challenges that you are working with at this time? If yes, please tell me a little more so that I can support you and offer ideas to help you further.

How do you wish to pay (397)? *

Check

Credit Card

Venmo

PayPal

Work out a payment plan with Amy

Terms of Service-I understand that Amy Hillman-Siracusa is not a doctor. She is an educated and qualified health professional who holds a Master’s degree in Holistic Health Education with a specialization in Holistic Nutrition from John F. Kennedy University and is a nationally board certified Health and Wellness Coach by the Board of Medical Examiners. Amy's scope of practice dictates that she may provide guidance pertaining to the building and maintenance of health and nutritional well-being. The information offered in the workshop, is provided for informational purposes only. It should not be used in place of a visit with, call to, or advice from a medical doctor. CANCELLATION & REFUND: If you need to withdraw from the workshop, please inform Amy via email as soon as possible. Cancellations made up to one week before starting (3/14/23) will be refunded 50%. No refunds are issued after the workshop starts on March 21, 2023.

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