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Please complete this application so we can better understand your unique situation and how we can best support you on your journey. We will review your application and respond within 48 hours.

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Name*

First Last

Email*

Phone*

What is/was your cancer diagnosis?*

What are your top 3 health challenges currently?*

How would your life be different if your health challenges were resolved in the next year?*

What approaches have you tried already that worked for you? Please list.*

What approaches have you tried that did NOT work for you? Please list.*

What changes do you know you could / should make that you haven’t already made?*

What are the biggest barriers to making the changes you already know you should be making?*

On a scale of 1 to 10, how committed are you to making the changes you need to make to achieve your health goals?*

What is the one change / new behavior you commit to making this week that will move you in the direction of your health goal?*

How did you hear about us?*

Dr. Nasha Winters

Friend

Podcast

Other

What is the name of the friend that referred you to us?*

Which podcast were you listening to when you heard about us?*

What is the Other way you heard about us?*

Do you have the financial means to invest in your health right now?*

Would you like to speak to one of our staff before getting started?*

Yes, (15 minute call)

No, I'm ready to get started