Let's find out if we're a great fit for each other
Please fill out your information below and we'll be happy to see how we may best serve you!
In your opinion, what makes you a good fit for our practice?
Full Name
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Valid Email
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Phone
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I live in Kansas/Missouri
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Yes
No
Are you on any medications? If so, what for?
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How old are you?
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What are you the top health concerns that you would like us to help you overcome?
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What would life be like is you were to overcome your health challenges?
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We will guide you on a healing journey requiring consistent participation. How motivated are you to work on yourself to feel better?
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I am VERY MOTIVATED to do some work on myself.
I am INTERESTED IN STARTING some changes.
I am UNSURE how much energy I can dedicate to working on myself.
I am NOT READY to participate in changing my routine
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Considering your past treatments, what would you like to improve or do differently moving forward?
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Do you consider yourself coachable?
Yes
No
What functional lab testing have you done previously?
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Functional Stool Testing
Organic Acids Testing
Adrenal/Cortisol Testing
Genetic or Genomic Testing
Hormone Testing
Food Sensitivity Testing
Heavy Metal Testing
None
Other
If Other:
Who else have you worked with?
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Functional Medicine Practitioner
Medical Doctor/Osteopathic Doctor
Medical Specialist
Naturopathic Doctor
Traditional Chinese Medicine
Nutritionist/Dietician
Personal Trainer
Chiropractor
Personal Development Coach
Other
If Other:
Do you have a supportive spouse, significant other, or friend to support your personal goals?
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Yes
No
What are the characteristics that you value most in a professional partnership?
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How Did You Find Us?
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Social Media
Google Search
Word of Mouth
Patient Referral
IFM Website
Provider Referral
Other
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Are you willing to do what's necessary to reclaim your health? (This may include dietary modifications, functional lab testing, lifestyle and environmental modifications, etc)
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Yes
No
Our practice is a cash-only practice and we don't accept any insurance. *
Yes, I understand
No, I am unwilling to pay out of pocket
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