Breakthrough session form Your name * Your email address * Your country * If you live in the US, which state do you live in? Your age * Your height * Your weight * Which outcome or outcomes would you most like to achieve during your Breakthrough Session? * On a scale of 1 to 5, how important is it to you that you achieve this outcome (or these outcomes) with 5 being not very important and 1 being essential? If you've listed more than one desired outcome, please rate each one! * Are you interested in booking a 50-minute session ($97) or a 90-minute session ($147)? * 50-minute session 90-minute session Not sure yet Are you currently dealing with any of the following health or wellbeing challenges? Please select all that apply * Anxiety Arthritis Asthma Cancer Depression Diabetes Eating disorder Excess weight Feeling stuck/unable to move forward in life Food cravings Frequent colds or infections Headaches or migraines Heart disease High blood pressure IBS or other digestive issues Insomnia Low self-esteem M.E. or chronic fatigue Panic attacks Period pain or PMS Skin condition (for example acne or psoriasis) Swollen or painful joints Other (I'll ask you about this during the call) Are you taking any medications (prescription or over-the-counter)? If so, please list here * Where did you first hear about this website? * Internet search On Facebook On Twitter A friend or family member told me I don't remember Other Thank you so much for your responses! Before you hit SUBMIT, is there anything else you'd like me to know – or do you have any questions about this service?
