Break the Cycle Call

Full Name *

Email *

Phone

Best time to reach you?*

What have you tried so far that hasn't worked for you?*

Please rate your stress levels on a scale of 1-10 (10 being high)*

How would you rate the pace of your life: Very fast paced (busy), little free time (moderate slow), or relaxed?*

Do you experience any troubles with digestion? (constipation, diarrhea, IBS, colitis, acid reflux, etc.)*

How do you sleep at night?*

How much water do you drink per day?*

Do you eat when you are bored? or stressed?*

Are you addicted to any of the following: caffeine, sugar, alcohol, or cigarettes?*

What type of exercise do you like best?*

Do you take any supplements, if so please list:*

What would you like to be different 6 months from now?*

Do you prefer group or individualized support?*

Please share anything that will help prepare for our meeting.*