Please fill the following ^*

First Name ^*

Last Name

Email ^*

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Do you live in New York, New Jersey, or Rhode Island? ^*

Yes

No

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Why are you here? ^*

Acne

Acne + other symptoms

Other

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How long have you been struggling with your symptoms ^*

Less than 1 year

1-3 Years

3-5 Years

5-10 years

More than 10 years

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What have you already tried? ^*

Prescription Topicals

Birth Control

Spironolactone

Accutane

Functional Medicine

Holistic Practitioner

Elimination Diet

Supplements

Other

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What previous testing have you done? ^*

Bloodwork

GI-MAP

DUTCH

HTMA

Toxin Panel

Tickborne Panel

Other

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What has been your biggest frustration in trying to address your symptoms? ^*

/

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How would you describe your current health? ^*

Excellent

Good

Fair

Poor

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Why are you interested in coaching now? ^*

/

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Coaching is designed to help identify and address factors contributing to symptoms over time. Which statement reflects your expectation? ^*

I understand healing takes time, is not linear, and am prepared for a long term approach

I am looking for a shorter term approach

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Are you willing to consistently implement recommendations for the duration of the program, meet monthly, and stay on track. ^*

Yes

No

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Private Coaching is a 6 month investment ^*

Supplements, Skincare, and additional testing are purchased separately and are not included in the monthly coaching fee.

Do you understand and acknowledge this investment?

Yes

No

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In addition to coaching, most clients should anticipate investing in laboratory testing and supplements throughout the program. ^*

Select laboratory testing is included in the program, including comprehensive bloodwork completed twice throughout our time together and a GI-MAP stool test. Supplements are purchased separately based on your individual recommendations. Additional testing may be considered as needed and is available at an additional cost.

Are you financially prepared to make these investments if recommended?

Yes

No

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If private coaching isn't the right fit right now, would you be interested in our Group Coaching program? ^*

Group Coaching provides a more affordable way to receive personalized guidance. You'll receive a customized protocol based on your bloodwork, plus weekly group coaching calls where you can ask questions and receive ongoing education. While you won't have direct 1:1 access to a practitioner, you'll still be guided every step of the way.

I want to proceed with Private Coaching Application

I would like to apply for Group Coaching

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If selected, how soon are you hoping to begin? ^*

Immediately

Within 30 Days

Within 60 Days

Just Gathering Information

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Is there anything else you would like us to know before reviewing your application ^*

/

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Do you believe you can heal? ^*

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Thank you for applying! 🙌

Coaching is designed for individuals seeking personalized guidance, accountability, and long-term support. Applications are reviewed to ensure the program is the right fit for both the client and practitioner.

If accepted, you will receive information regarding next steps and enrollment options.

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Group Coaching

No Enrollment Call required! CLICK HERE to join the waitlist.

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NY, NJ, RI

Important Lab Shipping Information

If you live in New York, New Jersey, or Rhode Island, state regulations prevent most functional lab companies from shipping testing kits directly to addresses within these states or practitioners from ordering your labs within these states.

If lab testing is recommended during your program, you'll need to provide a shipping address in another state where your kit can be delivered.

If you do not have an alternative address, please email [email protected] for more information.

This is a state requirement and applies regardless of the provider ordering your labs.

Please Restart this application and do not use a NY, NJ, RI address.

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Group Coaching

NY, NJ, RI