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We are a private pay practice and do not accept insurance? *

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To become a patient and schedule this call, you must be 18 years or older. *

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Date of birth *

I understand that I must be a California resident to be seen as a patient. *

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Please confirm you are aware this call will be on Zoom and will require your full attention. If you are driving during this call, we will need to reschedule. *

The prospective patient MUST be present on the call. *

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What is your top challenge that you would like us to help you overcome? *

How long have you been experiencing this/these issue(s)? *

Less than 3 months

3–12 months

More than 3 years

How much do your symptoms interfere with your daily life (work, sleep, mood, relationships, etc.)? *

On a scale of 1 to 10, how would you rate your overall health right now? *

(1 = worst you’ve felt, 10 = optimal health)

Do you believe your symptoms have improved, worsened, or stayed the same in the past 6 months? *

What have you tried to feel better? *

Considering your past treatments, what would you like to improve or do differently moving forward? *

How many different providers have you seen for this issue? *

Have you done testing or lab work in the past 12 months related to this issue? *

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→ If yes: ➤ What kind of testing?

Are you currently on any prescription medications? *

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Do you follow a particular diet or nutrition plan? *

We will guide you on a healing journey requiring consistent participation. How motivated are you to work on yourself to feel better? *

In a few sentences, why do you think our office might be right for you. *

Are you comfortable using an online health portal, accessing telehealth visits, utilizing an online educational platform? *

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