530-4416651

YUBA CITY | LINCOLN | ROCKLIN

First Name *

Last Name *

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What are the main health concerns or symptoms you're currently dealing with? *

How long have you been dealing with these issues? *

Less than 3 months

3–12 months

1–3 years

Over 3 years

How are these issues affecting your daily life? *

What have you already tried to improve your symptoms? *

What would your life look like if you could resolve these issues in the next 6–12 months? *

How committed are you to making your health a top priority right now?

100% ready — I’ve tried enough and I’m done guessing

Somewhat ready — I want help but still doing research

Just curious — I’m not ready to take action yet

Are you open to investing time, energy, and financial resources into your health if we find that you're a good fit for our program? *

Yes, absolutely

Possibly — it depends on the program

No — I’m not in a place to invest right now

What’s your biggest concern or fear about starting a new health program?

Why do you feel now is the right time to make a change?

On a scale of 1–10, how important is it for you to get to the root cause of your health issues? 1 = Not important / 10 = Extremely important

Is there anything else you'd like us to know before we reach out by email or schedule a call with you?