Intake Form - ALISON VICKERY

***Please do not fill out this form if you’re not serious about potentially working together at this time. Waiting until you are ready will optimize your chances of us being a good fit. Please also note that I do not advise people who are not my clients. ***

Thanks so much for applying to work with me. I am excited to see if we are a good fit.

Please answer the following questions.

If I think I can help, I will provide you with a link to book a free zoom call to discuss working together and the best package for you.

I have an extensive waitlist and will be back to you as soon as possible.

First Name

Please confirm that you are NOT: Under 25 years of age; Pregnant, attempting, to get pregnant or breastfeeding; Unwilling to take any supplements; Eat less than 12 foods; Are a vegetarian; On two or more prescription medications; Have cancer or a history of cancer; Are currently in mould with mould illness; Have a diagnosed chronic mental health condition

Where are you located (I work with people all over the world – so this is just to see if I currently have times available in your time zone)

What is your occupation (if any)?

What are your main health concerns that you want help with? Please only list the top 3 that are the priority for you right now.

What have you tried in the past to get on top of your health concerns?

Are any other health practitioners currently involved in your care or have they been involved in your care in the last six months? If so what are you seeking from me that you have not got from them?

How committed are you to making the changes I may suggest for you? In order to improve your health, how willing are you to do the following? Please rate on a scale of: 1 (not willing) to 5 (very willing). Significantly modify your diet (e.g. remove all gluten and alcohol)

Please rate on a scale of: 1 (not willing) to 5 (very willing). Take several nutritional supplements each day

Please rate on a scale of: 1 (not willing) to 5 (very willing). Modify your lifestyle (e.g. work demands, rest, sleep, habits)

Please rate on a scale of: 1 (not willing) to 5 (very willing). Practice stress management techniques

Please rate on a scale of: 1 (not willing) to 5 (very willing). Resolve any emotional or mindset blocks

Please rate on a scale of: 1 (not willing) to 5 (very willing). Engage in regular exercise

Please rate on a scale of: 1 (not willing) to 5 (very willing). Have periodic ART or functional tests to assess progress

Please rate on a scale of: 1 (not willing) to 5 (very willing). Prioritising your own health issues

Is there anything else you feel is important for me to know?

How much financially are you willing to spend on your health?

Which of my programmes are you interested in?

*** Thank you ***

This information will enable me to work out the best way of helping you. I will be back to you as soon as possible.

WANT TO LEARN MORE?

Access my FREE
Roadmap To Resolution Course

WANT TO LEARN MORE?

Access my FREERoadmap To Resolution Course

Access my FREE
Roadmap To Resolution Course