Initial Contact Form

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We would love to help everyone, but unfortunately we cannot. To quickly discern whether or not we can help you we have established a brief screening form. By completing this confidential form, we ensure that we will have a good idea of your expectations and the problems you are struggling with. We will contact you shortly.

Fields marked with * are required.

Email Address *

First Name *

Last Name *

Phone number *

I prefer modern medicine to solve my health problems

What is your current health problem?

How long have you been struggling with your health problem?

What are your current health goals?

How many professionals have you seen for this problem?

How long are you willing to commit to natural treatment to reach your goal?

Can you commit financially to a monthly out of pocket expense from $160-300?

Are you willing to take and pay for multiple supplements to reach your health goals?

Why have you contacted us specifically?

I am currently being treated for psychological problems.

I am a really picky eater or am currently very limited in the foods I can or will eat.

Please provide any other relevant information.

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