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Thank you for considering working with Jeremy here at Gilsoul Health! I am thrilled to be

supporting you on your healing journey.

To help me understand how best to help support you please fill in the form below with your interest,

and our team will reach out to schedule your complimentary care assessment or,

arrange payment if applicable.

What is your Full Name? *

What is your best email? *

What is your best contact number? *

What is your Date of birth? *

What is your zip code? *

Are you a current or former client of Jeremy’s? *

Yes

No

Are you seeking? (Check all that apply?)

Acupuncture for Pain (In Person)

Acupuncture for Stress Support (In Person)

Sleep Support (Vibrational Medicine)

Mindset Coaching (Remote)

Nutritional Consulting (Functional Medicine)

Health Testing (Functional Medicine)

Gut Health (Functional Medicine)

Supplement Review (Functional Medicine)

Please answer the following questions as openly and honestly as you can:

What are the biggest challenges you have that you would like me to support you with? Examples: Gut health concerns. Hormone dysregulation. Food sensitivities. Fatigue. Mental/emotional stress. Pain. Earn more money. Whole life changes. Etc.? *

Are there any secondary or more concerns? *

What have you tried to do to resolve the concerns and issues you've listed? Did it work? *

What is NOT resolving these concerns costing you? *

How much longer are you willing to deal with the concerns you listed? *

What do you want instead? *

What would your life be like if you were able to get fast results and dramatically improve your life? *

How will you know things are improving? *

On a scale of 0-10 (where 10 is the highest), how committed are you to getting this concern(s) resolved? *

Do you have a time frame you want to get started? Sometimes Jeremy has more immediate openings and sometimes it is a couple months out. *

Anything else we should know? *