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Step 1 of 11

On a scale of 1-10 rate your physical energy level (1 being the lowest to 10 the highest)

On a scale of 1-10 rate your mental clarity, ability to focus & create?

On a scale of 1-10 how would you rate your emotional wellbeing?

Tell me about your physical symptoms & how they affect your life?

Tell us about your mental & emotional symptoms & how they affect your life?

What would you want to experience instead: physically, mentally, & emotionally?

What would you be able to accomplish if you were at your best?

What's getting in the way of you reaching your health goals? Be specific & honest as possible.

What health approaches have you tried in the past?

Do you believe it is important to invest in your health?(Required)

Yes

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How much would you be willing to invest in a solution that works for you? Please be as accurate as possible here*

Your response doesn't change our pricing... but it helps us understand your budget, program options within your budget and importance.

Don't have the finances now, but maybe in the future.

$200 to $1K - As much as a nice TV or Furniture

$1K to $3K-- As much as a nice vacation

$3K to $5K-- As much as a bathroom upgrade

I'll invest what I need to as long as it works for me

Your Name(Required)

Your Email(Required)

Best Phone Number(Required)

Date Of Birth(Required)

MM slash DD slash YYYY

What is your zip code?(Required)

How did you find out about Dr Rajka? And what made you want to expore working with her?(Required)

Phone

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