Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

What is your age? *

13-17

18-25

26-35

36-50

Over 50

Prefer not to say

Gender *

Male

Female

Other

Check all that apply. Be honest with yourself. *

I don't feel great in my body.

I'm not happy with my weight.

I'm tired

I'm too busy.

I don't feed myself as well as I should.

I'm not getting enough exercise.

I'm easily overwhelmed.

I sabotage myself with negative self-talk.

Are there any current physical issues that you are struggling with? *

Yes

No

Are there any current mental, emotional or spiritual issues that you are struggling with? *

Yes

No

Are you struggling with any of the following issues? *

Eating a less than optimal diet

Not sleeping well at night.

Relying too much on caffeine for energy.

Eating too much sugar.

Experiencing lots of stress in my life.

Experiencing anxiety.

Experiencing depression.

Feeling distracted rather than purposeful.

Not feeling deeply connected to myself.

Not feeling deeply connected to community.

Which of the following areas are you interested in working on to improve your overall well-being and healthy lifestyle? Mark all that apply. *

Better understanding my constitution

Planning healthy and delicious meals

Getting more exercise

Starting or deepening my yoga practice

Learning the keys for experiencing more energy

Prioritizing nourishing self care

Establishing a solid daily routine for health

Replacing my not-so-good habits with better habits

Preventing overwhelm

Learning tools for managing anxiety

Learning tools for managing depression

Getting more clear and purposeful with my life

Improving my time management

Starting of deepening a meditation practice

Making time for the Sacred

Loving myself more deeply

Learning to age more gracefully

Learning how to live a more easeful life

10 Weeks to YOUR RADIANT BODY is about up-leveling your habits and wellness so you can live a happier, healthier life. What do you want? *

I want to take better care of myself.

I want to eat a healthier diet.

I want more energy.

I want to prepare healthy food for myself and family.

I want to understand my personal constitution.

I want to exercise regularly. (Either learn how or do it consistently.)

I want to meditate. (Either learn how or do it consistently.)

I want to feel better in my body.

I want to feel better in my mind.

I want to feel more ease in my life.