Personal Information

Getting to KnowYou
Information that Helps me Help YOU!
Please submit before our first consultation

First Name

Last Name

Email Address

Age

Please list your top three areas of concern/focus

Please list any medical issues or concerns including diagnoses, Pregnancy, Implants, Pacemaker, Surgical Mesh, Surgery/Scars, Broken Bones, Spinal Rods/Metal Pins, Advanced Osteoporosis, hypermobility...anything that might be impacted by Block Therapy

Are you right or left handed?

How much time per day can you devote to the practice of Block Therapy? There are no right or wrong answers. This helps me develop the program that best fits your needs within your schedule.

Indicate which Block Therapy tools you own (Block Buddy, Block Baby, Block Paddle) and if you have purchased a Starter Program, Membership, or neither

Please explain your experience with Block Therapy. Helpful information is what recent classes you've done, your level of pain, what limitations you have, what challenges you've encountered, and how long you've been doing Block Therapy.

What are your expectations and goals for us working together?

How would you like me to pray for you as you begin your journey?

Answer the following if you would like us to work together to improve your health with nutrition.

Give me some insight into your current nutrition plan/way of eating, including food allergies and sensitivities.

Do you have any current struggles with food? What are your biggest challenges with eating healty?

What's important for me to understand about your journey with eating, your current weight, or the way you want to go forward with nutrition? What has been misunderstood that you need someone to hear?

Photo Submission

Programs & Appointments

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Getting to KnowYou Information that Helps me Help YOU! Please submit before our first consultation

Getting to KnowYou
Information that Helps me Help YOU!
Please submit before our first consultation