Exit this survey

This short survey allows us to get a snapshot of your needs and desires for nutrition counseling services. Upon completion of the survey, you'll be able to schedule a complimentary Strategy Session with a Functional Nutrition Alliance nutritionist to discuss our services and help you determine how our nutrition counseling can best fit your needs.

Are you ready for a fully supported health transformation? It all starts here!

Question Title

* 1. What is your name (please include first and last names)? (* Required)

Question Title

* 2. What email address may we use to contact you? (Please use the same email address you've used with the Alliance Clinic already so we may continue to send you helpful tools and tips.  Please ensure this is correct!)

Question Title

* 3. We'd love to know where you are located.

Question Title

* 4. If you live within the U.S., in what state or territory do you live?

Question Title

* 5. What city or town do you currently live in?

Question Title

* 6. Are you filling this survey out for yourself or on behalf of another person?

Question Title

* 7. We'd love to know how you found us or who referred you. (Please first choose a category and then provide us the specific resource below.)

Question Title

* 8. Please identify specifically how you found us. (For example, the name of the podcast or the name of the person who referred you.)

Question Title

* 9. What are your main goals for seeking nutrition counseling with the Alliance Clinic? (Select all that apply)

Question Title

* 10. Do you have any known health or medical conditions or diagnosis that we should know about in helping you to find the best care? If yes, please explain.

Question Title

* 11. What have you tried so far to address your goal? (Diets, testing, modalities, etc.)

Question Title

* 12. Which of the following items are currently in your diet in any amount: (select all that apply)

Question Title

* 13. What percentage of your meals are currently home cooked?

Question Title

* 14. I have participated in other Functional Nutrition Alliance (formerly Replenish) programs:

Question Title

* 15. Please let us know anything else about you, your goals for nutrition counseling with the Alliance Clinic or your health aspirations.

Question Title

* 16. We are committed to working with individuals who are dedicated to their health and ready to receive support on their individualized journey to health and healing. We're uniquely poised to uncover and unlock the evolving protocol that will deliver the results you've been seeking. In two or three sentences, tell us something about yourself and/or your health history that will help us get to know you before we take any further steps to dig more deeply into the details of your concerns. When you're done, be sure to hit the orange button to schedule your complimentary Strategy Session.

T