Barrier Breakthrough Questionnaire

RECLAIM YOUR HEALTH, RECHARGE YOUR LIFE!

Must Complete Before your Call

Fill out the form below to submit all of your information needed and to lock in your scheduled appointment time.

First Name *

Last Name *

Phone *

Email *

Please describe your top three goals. Weight loss? Reduce stress? Disease prevention? All of the above? *

What do you think is getting in the way of those goals? *

What is your urgency for solving this on a scale of 1-10? (10 is high - YES, I'm ready to get the support I need and do what it takes, 1 is low - I've got 10 million things to do and this always falls last) *

On a scale of 1-10 (10 being yes, I'm ready), how are ready are you to invest in yourself and your health in order to move forward? *

What do you hope to gain from our session? *

Where did we meet you? *

The Legal Stuff

The government and lawyers make me do it!

Health Disclaimer *

As with every health & wellness program, please check with your medical doctor before starting. The information provided by my services is for educational purposes only. The information I provide is not intended to serve as medical advice and should not be used for the diagnosis or treatment of a health problem or disease. *

Yes, I have read the disclaimer and both understand and agree to the terms stated

Ready, let's go!

Click submit to get started! Can't wait to meet you!

support@completehealthrevolution.com

(513) 547-3655