Personal Information

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 and your goals for your assessment and coaching

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 do you want people to know about your journey with eating, your current weight, or the way you want to go forward with nutrition?

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Programs & Appointments