Wellness Coaching Application

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Thank you for your interest in working with me! If it's a good fit, you will receive an email with details on getting started and we'll schedule your sessions. If not, I will do my best to direct you to a resource or person who can help you.

Email *

Name & phone # *

How did you hear about me? *

What are your top 2 health and wellness goals? Please be as specific as possible. *

Briefly describe your biggest health concern and why do you want to solve this problem right now? *

What have you already tried to resolve these problems? *

How are these issues holding you back from your life, career and aspirations? *

Why is now the right time for you to address these issues? *

Age *

Do you think friends and family will be supportive of you making changes to improve this problem? *

Yes

What would you like help with? Check all that apply: *

Weight loss

Nutrition

Eco friendly lifestyle, reducing my toxic load & detoxing my home

Reducing my toxic load and transitioning to a clean, eco beauty & personal care routine

Intermittent Fasting Lifestyle

Mindset & life coaching

Kelly, if I am selected and decide to work with you, I’ll find a way to invest in myself and my future: *

I have the necessary means to invest in my health and future

I have the ability to get the necessary means to invest in my health and future

I have no financial means to invest in my health and future

On a scale of 1 to 10 how committed are you to learning and making the changes you need so you can reach your goals? *

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