Apply to Work with Me!

You’re here for a reason. Something inside you is ready for change, and this is where we begin.

Filling out this form helps me know you are committed to your health and allows me to learn more about where you are now and what may be holding you back.

Once you click submit, you'll be automatically directed to a page to book a Complimentary 30min Strategy Call.

Full Name

Phone Number

Age

Referred by/How did you hear about me?

What brings you to apply today? This is your space to share what’s been weighing on you and what you’re hoping to work on. This helps me understand the right next step for you. Tell me a bit about what you’d like support with—weight loss, hormones, energy, metabolic health, or anything else you feel stuck on.

Have you worked with an integrative or functional practitioner before?

Yes

What do you feel has made progress feel difficult or unsustainable in the past?

Feeling confused by conflicting advice

Diets that worked temporarily but never lasted

Low energy, burnout, or stress

Hormonal changes (PCOS, postpartum, perimenopause, etc.)

Weight that feels “stuck” no matter what you do

Lack of personalized guidance or accountability

Feeling like you had to be perfect to succeed

Time constraints or competing priorities

Something else

If you selected “Something else,” please share below.

So far in your journey, what have you tried to lose weight and improve your health?

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 structured program with accountability

Regular communication between appointments

Lab testing and evidence-based supplements

Nutrition, lifestyle and educational resource

Are you aware that this is a concierge, physician-led practice (no insurance billing, high-touch care)?

Yes

No, I’d like to learn more.

What is your preferred level of communication and access to your provider?

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?

$500-5,000

$5,000-10,000

$10,000-15,000

$15,000-20,000

$20,000+

Is there anyone else (spouse, partner, or parent) involved in your decision-making process? If so, will they be attending the call?

Yes, they will be attending.

Yes, but they will not be attending.

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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