Let’s find out if we are a great fit for each other…
Please fill out your information below and we’ll be happy to see how we can best serve you.
First Name *
Last Name *
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What is your preferred method of contact?
If other, please specify:
What is your top challenge that you would like us to help you overcome? *
Why is this goal important to you? *
What is stopping you from accomplishing this goal? *
If you were to wake up tomorrow without this challenge, how would your life be different? *
What are your top motivating factors to invest in solving this problem? *
Do you consider yourself coachable? * Do you consider yourself coachable?*YesNo
Do you have a supportive spouse, significant other, or friend to support your personal goals? * Do you have a supportive spouse, significant other, or friend to support your personal goals?*YesNo
Have you experienced significant trauma (emotional, physical)? * Have you experienced significant trauma (emotional, physical)?*YesNo
What are the characteristics that you value most in a professional partnership? *
Who else have you worked with?
Functional Medicine Practitioner
Traditional Chinese Medicine
Personal Development Coach
What functional lab testing have you done?
Functional Stool Testing
Organic Acids Testings
Genetic or Genomic Testing
Heavy Metal Testing
Considering your past treatments, what would you like to improve or do differently moving forward? *
Are you willing to do what’s necessary to reclaim your health? (This may include, dietary modifications, functional lab testing, lifestyle and environmental modifications) * Are you willing to do what’s necessary to reclaim your health? (This may include, dietary modifications, functional lab testing, lifestyle and environmental modifications)*YesNo
What else would you like us to know so we can best serve you? *
1 + 4 = ? Please prove that you are human by solving the equation *
7 Spectrum Loop, Suite 145
Colorado Springs, Colorado 80921
Total Skin Restoration
Total Body Transformation
Erectile Dysfunction Treatment
Growth Hormone Therapy
Stem Cell Injections
We have some precautions in place for the protection of our patients and staff–but we are treating patients. Call us! We are happy to help you!
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