Application for Care
PLEASE ANSWER THE QUESTIONS BELOW IN DETAIL.
THIS APPLICATION WILL HELP BETTER ASSESS YOUR INDIVIDUAL PATH TO WELLNESS.
1) Name:*
Required field!
Date of Birth*
Required field!
2) Email*
Required field!
3) Phone*
Required field!
4) Where are you located? Please include the State (if relevant) and Country*
Required field!
.
Required field!
5) How did you hear about Cypress Natural Medicine / Revolutionary health? If referred by someone, who are they?
Required field!
6) What are the specific health challenges you are seeking health with?
Required field!
7) Where do you feel your health is right now?
Required field!
8) What do you feel your biggest obstacles to healing are?
Required field!
9) How will your life change if you overcome these challenges?
Required field!
10) What is your previous experience with functional and/or natural medicine?
Required field!
11) How financially ready are you to invest in your health over the next year?
Required field!
12) How committed are you to following diet and lifestyle changes and treatment plans?
Required field!
13) How open are you to changing your daily habits?
Required field!
14) How intensely is your health impacting your life?
Required field!
15) Do you trust that you can regain your health?
Required field!
16) What questions do you want to make sure we address during our Alignment Call?
Required field!