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Wellness Consult

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Question 1 of 13

Full Name

Question 2 of 13

Email

Question 3 of 13

Instagram Handle

Question 4 of 13

Preferred Method of Contact

(Select all that apply)
A

Email

B

Instagram

Question 5 of 13

Which program are you most interested in?

A

Wellness Influencer (start making extra income)

B

Customer (just interested in buying the coffee, not making extra income)

Question 6 of 13

If you're interested in earning extra income, how much are you willing to invest to start working with me?

A

$100 - $300

B

More than $300

C

Not Interested

Question 7 of 13

How much are willing to invest in yourself? What is your budget (in US dollars)?

A

$50 - $120

B

$120 - $200

C

$200 or more

Question 8 of 13

Are you sensitive to caffeine?

A

Yes

B

No

Question 9 of 13

Do you enjoy drinking coffee or would you prefer a Watermelon Berry flavor?

A

Coffee

B

Watermelon Berry

C

I would love to try both!

Question 10 of 13

How much water do you typically drink daily?

A

Half my body weight

B

At least 80 ounces

C

I have a hard time drinking water

Question 11 of 13

Do you make a bowl movement daily?

A

Yes

B

No

Question 12 of 13

Do you struggle with losing weight and/or maintaining it?

A

Yes, I'm trying everything & nothing seems to work

B

No, I'm losing weight at my own pace

C

No, I'm healthy & I'm able to maintain my weight

Question 13 of 13

Check all that apply that you currently experience.

(Select all that apply)
A

Fatigue / Exhausted

B

Brain Fog / Reduced Mental Focus

C

Restless Sleep / Wired / Sleep Insomnia

D

Inflammation / Acne / Swollen / Puffiness

E

Digestive / Gut Issues

F

Mood Swings / Irritable

G

Anxiety / Racing Heart

H

Body Aches / Joint Pain

I

Eye Twitching / Stressed Out

J

Belly Bloat / Weight Gain

K

Sugar / Food Cravings

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