check

Private Hormone Coaching Application

Thank you for your interest in working together. This application is for women who are ready to take action on their hormones, cycles, weight, acne, bloating, energy, and fertility goals through personalized coaching support. Please answer honestly so we can determine whether this program is the right fit for you.

Click the button below to start.

Start

Question 1 of 17

What's Your Name and Age ?

Question 2 of 17

What are your top 3 concerns right now?

(Select all that apply)
A

Irregular periods

B

No ovulation

C

Difficulty conceiving

D

Failed IVF, IUI, or recurrent miscarriage.

E

Weight gain / difficulty losing weight

F

Low energy / motivation

G

Acne, Bloating

H

Low energy, Mood swings

Question 3 of 17

Have you been diagnosed with PMOS/PCOS or another hormone-related condition?

A

Yes, PCOS

B

Yes, another condition

C

Suspected, but not diagnosed

D

Not sure

Question 4 of 17

 What best describes your cycle right now?

(Select all that apply)
A

Regular monthly cycle

B

Irregular, but comes monthly

C

Skips months

D

Very long cycles

E

No period currently

F

Only bleed with birth control or medication

Question 5 of 17

Are you currently trying to conceive?

A

Yes

B

No

C

Planning to in the future

Question 6 of 17

 How long have you been dealing with these symptoms?

A

Less than 6 months

B

6–12 months

C

1–2 years

D

2–5 years

E

5+ years

Question 7 of 17

What would you like to accomplish in the next 3 months?

Question 8 of 17

If this program worked well for you, what would be different in 90 days?

Question 9 of 17

Why is now the right time for you to get support?

Question 10 of 17

How motivated are you to make changes right now? Scale 1–10

Question 11 of 17

How committed are you to following a personalized plan for 3 months?   Scale 1–10

 

Question 12 of 17

How open are you to making changes to your nutrition, habits, stress, sleep, and movement if needed?

A

Very open

B

Open, if the plan feels realistic

C

Somewhat open

D

Resistant right now

Question 13 of 17

Have you tried to improve your hormones or symptoms before?

A

Yes, many times

B

Yes, a few times

C

No, this is my first time

D

I’ve tried but never stayed consistent

Question 14 of 17

What have you tried so far, and what were the results?

Question 15 of 17

 What do you think has been your biggest barrier to progress?

(Select all that apply)
A

Lack of clarity

B

Inconsistency

C

Lack of support/accountability

D

Emotional eating

E

Lack of time

F

Stress

G

Medical complexity

H

I’m not sure

Question 16 of 17

Is there anything medically going on that could affect your ability to fully participate in coaching?

Question 17 of 17

Do you understand that coaching is not medical treatment and does not replace care from your doctor?

A

Yes

B

No

Confirm and Submit