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Optimal Wellnesss & Nutrition Program
Pre-Screening Form

To move forward with your pre-screening for the Optimal Wellness and Nutrition Program, please complete this form at your earliest convenience for review.

Thank you!

Do you identify as neurodivergent?
Yes
No
I don't know

Read about Neurodiversity by the following link: https://www.health.harvard.edu/blog/what-is-neurodiversity-202111232645

Achieving good health involves an investment of time, effort, emotions and personal development work. Knowing this, how ready are you to take action and invest in yourself to achieve your goals?
I’m extremely ready, and ready to invest in myself.
I'm ready but need more info.
I'm not very ready.

For example: If you want to give money, state how much. This could be financial, or it could be something else that holds value to you. For example, if you’d like to contribute money, simply state the amount you’re offering. If you prefer to give a physical gift, let me know what it is. Or, if you’d like to offer a skill or service in exchange, feel free to share—whether it’s a yoga class, an art session, a ceramics workshop, or something else that reflects your unique talents and passions.

Do you have any current lab reports from the past 6 months to a year that you can share?*
Yes
No
In the process of obtaining
If you do not have current lab reports from the past 6 months to 1 year, and are unable to obtain them from your physician or medical center, we would be happy to assist you with lab testing. Are you interested?
Yes
No

Please note: There will be additional fees, but we will provide you with a list of available tests along with their prices and guide you through each step of the process.

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