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Application to work with KB Wellness

At KB Wellness we have several ways to work together ranging from courses and a membership club, to one on one coaching to work on diet and lifestyle, all the way up to a 3:1 team of practitioners tackling your labs, protocols, diet and lifestyle and more.

This application will help me gain a preliminary understanding of what your needs are so we can help you find what program is right for you! 

 

I look forward to connecting with you!

Start

Question 1 of 13

What's your first and last name? 

Question 2 of 13

What is your age?

Question 3 of 13

What is your email address?

This is how I will be in touch after receiving this application.

Question 4 of 13

How did you hear about Kristen Blake Wellness and why do you feel like her practice would be a good fit for you?

Question 5 of 13

What are your biggest health struggles right now, how long have you been dealing with them, and what have you tried for them?  

Question 6 of 13

Which of the following have you worked with in the past or are currently working with? 

(Select all that apply)
A

Medical Doctor / Primary Care Physician

B

Naturopathic Doctor

C

Nutritionist or Dietician

D

Accupuncturist

E

Chiropractor

F

Therapist

G

Other

Question 7 of 13

 Are you currently taking any medications or supplements to treat or manage any of your health concerns? If so please list them below.

Question 8 of 13

Where do you want your health and your life to be 6 months from now?

Be as descriptive as possible. 

 

Question 9 of 13

Have you done any of the following lab testing within the past year?

(Select all that apply)
A

Stool test

B

Food sensitivity panel

C

SIBO test

D

Cortisol / Adrenal Test

E

DUTCH test

F

Bloodwork

G

Other

Question 10 of 13

At KB Wellness we have several ways to work with us. It's ok if you're not sure what will best meet your needs but if you do have a sense of what you're looking for please indicate below. 

 

1. Heal from Within - a one on one program where Kristen, and her team utilize functional labs, customized protocols and diet and lifestyle modifications to walk you step by step through the process of reaching your health goals. 

 

2. KB Club or KB Code - a self paced program or membership where you can go at your own pace. 

 

3. Jumpstart to Health - a shorter term nutrition and lifestyle focused program with KB Wellness' Registered Dietitian or health coach to help get you on the right track with your health.

 

4. Testing Package - a package of just 1-2 sessions with or without testing to point you in the right direction for you to implement changes on your own.

Question 11 of 13

 On a scale of 1 to 10, how committed are you to making changes to address your health complaints? Zero being not very close and 10 is I'm done messing around I'M ALL IN!!

 

Question 12 of 13

Packages range from $300/month to $1,000/month (self paced options range from $45 - $297). Are you in a place to invest at the moment? 

A

Yes, I'm in a place to invest in my health in a long term package in the range of $300/mo-900/mo

B

I'm not looking for long term assistance. I prefer a one time consult only ($350) or a testing package ($500-$1,500 range).

C

I'm not in a place to invest in a package in that range but I am in a place to invest in a self paced option or group program (ranging from $45 to $297)

D

I haven't decided at this time if I'm ready to invest in my health in this way

E

I am NOT financially able to invest in my health in any of those ways at this time

Question 13 of 13

 Is there anything else you'd like me to know?

Confirm and Submit