Quiz Application

Congratulations on deciding to take the next step towards bettering your health! Please take a few minutes to answer these questions. This will help us serve you better. After clicking submit, you will be able to schedule a 30 minute complementary call. Looking forward to serving you soon.

Name

First Name

Last Name

Phone number and timezone

(###)

###

####

How did you hear about us? Did someone refer you?

What is your main health problems?

How often does this bother you?

How long has this been going on?

What have you tried that has not worked

What does this prevent you from doing?

Is there anything that might stop you from completing a health rebuilding program?

What would you reasonably expect to achieve while working with us?

Do you have a phone, computer, internet and a quite place for sessions?

Do you keep appointments well or do you need reminders?

I need text reminders please

I need email reminders

I do not need any reminders

On a scale of 1-10. How willing are you to make necessary changes to get well? (10= very committed)

describe your commitment level

What is your budget for a health rebuilding program? This helps us create affordable programs

Money isn't an issue, I must get well

Between $3,000-$5000

Between $1,000-$3,000

Between $500-$1,000

I'm looking for free help

between $500-$300

Is there any questions or special information that you would like your practitioner to know?

AllSaints.Functional@yahoo.com