Name *

First Name

Last Name

Inquiring about

Food intolerances or allergies

Nausea, dizziness, or constipation

Chronic pain (Fibromyalgia, Endometriosis, etc.)

Chronic mood state (anger, depression, anxiety etc.)

Emotional stuckness (low energy, indecision, etc.)

Trauma recovery (rape, PTSD, divorce, etc.)

Long Covid

Emotional and/or sexual Intimacy

Life Transition (breakup, move, grief etc.)

Marriage or infidelity challenges

My child

My dog or cat

Other