Name * First Name Last Name Email * Phone * (###) ### #### Instagram Handle * Are you experiencing any of the following symptoms? (Check all that apply) * Bloating Digestive Issues Low Energy/Fatigue Anxiety Brain Fog Trouble Sleeping Are you currently satisfied with your skin? * Yes No Could be better Are you experiencing any of these common skin issues? (Check all that apply) * Acne Oily Skin Dry Skin Signs of Aging Fine Lines & Wrinkles Dark Spots/Age Spots Dull Skin/Lacking Glow Skin Rashes None of the Above Are you familiar with gut health and how this can affect your overall health, skin, and mental health? * I'm familiar, but could use more information Yes! I'm a gut enthusiast No What areas of your life would you want to improve? (Check all that apply) * Overall Wellness More Community/Friendships Mindset/Mental Heath Direction and Goal Setting Personal Development/Self-Improvement Would you like to hop on a 15 minute consultation call to discuss your survey? Yes! Not right now. Are there any other thoughts or desires you would like to share about your health and wellness? * Thank you!
