ACE Defying Wellness Program Application Please enable JavaScript in your browser to complete this form.Name *FirstLastEmail *Best Phone Number *Best days/times to reach you? *Do you have an ACE score of 1 or greater? *YesNoWhich of the following do you have symptoms of or have you been diagnosed with? *Anxiety, depression, bipolar disorder, other mental health concernHashimoto's, Grave's, lupus, RA, or other autoimmune diseasePMS, PMDD, PCOS, fibroids, endometriosis, infertility or other hormonal concernInsulin resistance, diabetes, high cholesterol, hypertension, heart disease, obesity, or other metabolic concernNone of the aboveOn the scale of 1-10 (with 10 being most motivated), how motivated are you to make long-term changes to improve your health. Consider these areas: diet restrictions, drinking herbal teas, eliminating personal care products, exercising regularly, and documenting your progress. Selected Value: 0 Do you plan to go on any extended personal or business trips that will last more than a weekend over the next 3 months that may make it more difficult to attend group meetings or stick to a new lifestyle (dietary changes, supplements, sleeping schedule, environmental toxins, etc.)? *Are you seeking help because you want to or because someone else wants you to? *I want toSomeone else wants me toOn a scale of 1-10 (with 10 being the most committed), how committed are you to seeking a comprehensive approach (that doesn’t include adding more pharmaceuticals) for at least a 3-month period? Selected Value: 0 Are you comfortable seeing a doctor by telehealth (phone or video call)? *YesNoIs there another decision maker who would have to approve your investment in our wellness program? *YesNoIs there anything else we should know about you (for example, details about symptoms or diagnoses, length of time you have been taking medications, dosages, practitioners visited, current location, and methods tried in the past)? *Submit