Health Intake Form (Pre-Program)

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Your growth in The Shift: A 12-Week Conscious Medicine Program to Revolutionize Your Health is our top priority. Your answers will determine the intent of the live sessions, and the more we understand your challenges and desires, the more we can give you the support you need.

This intake form also serves as a baseline for you to be able to track your progress, as you will fill out this same for again at the end of your 12-weeks.

Name*

First Last

Email*

1. What is your biggest health struggle right now?*

2. What motivated you to join The Shift: A 12-Week Conscious Medicine Program to Revolutionize Your Health?*

3. Describe the most important thing you want to learn, change, or accomplish as a result of The Shift: A 12-Week Conscious Medicine Program to Revolutionize Your Health*

4. On a scale of 1-10, 1 being the most unhealthy and 10 being optimal health, where do you feel your health is right now?*

Please enter a number from 1 to 10.

5. What is your hope and intention for this 12-week experience?*

6. How will you know if you’ve achieved that outcome? What external reality or concrete milestone will signal success? How will it feel emotionally when you get there?*

This field is for validation purposes and should be left unchanged.