First & Last Name
Email
Phone Number
Age
Referred by/How did you hear about me?
What brings you to this call? This call is a chance for me to learn more about you and your goals, and to ensure this is the right fit for your care. Please briefly share what you’d like support with -whether it’s weight loss, hormones, perimenopause/menopause or something else.
Have you worked with a functional medicine health coach before? Yes
No
What is the main area of your health that you’re hoping to improve or get support with? Balance hormones/manage peri-menopause/menopause symptoms
Weight loss
Body recomposition (lose fat/build muscle)
Build muscle and strength
Increase energy and reduce fatigue
Improve gut health and digestion
Fatigue or burnout
Improve sleep
Improve overall health and longevity
What has been the biggest obstacle in hitting your health goals?
So far in your journey, what have you tried to fix these symptoms/complications?
If we could wave a magic wand and help you feel your absolute best this year-physically, mentally, and emotionally- what would that look like for you?
How do you prefer to be supported in your care? In-depth visits with personalized guidance
A structure program with accountability
Regular communication between appointments
Lab testing and evidence-based supplements
Nutrition, lifestyle, and educational resource
What is your preferred level of communication and access to your provider/coach? Frequent check-ins and direct messaging
Weekly updates and calls
Monthly check-ins
I prefer less frequent communication, only when needed.
Why is it important that you solve these health challenges right now VS. a year from now?
When it comes to making your health a priority, what level of investment feels aligned for you? Under $2000
$2,000-4,000
$4,000-6,000
$6,000-10,000
$10,000+
How soon are you looking to start working with us? Immediately
Within the next month
Within the next three months
I’m just exploring options for now
What is the primary reason you are seeking concierge care over traditional care? More personalized attention
Access to longer appointments
Holistic care and support
Convenience and flexibility
How committed are you to making lifestyle changes to reach your health goals? Fully committed, willing to do whatever it takes
Somewhat committed, but need support
Looking for guidance, but not sure if I can fully commit yet.
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