Pre-enrollment Questionnaire

Your current health situation, lifestyle, and personal commitment to this self-help program must be discussed during your FREE phone or email consultation. A prior knowledge will help to facilitate the discussion and minimize phone expenses if a phone call is preferred.

Please answer the following questions as best as possible and agree to the terms of enrollment and we will contact you via your email address.

Associate Health History

Please note that all fields followed by an asterisk must be filled in.

Please enter the word that you see below.