Confidential Application for the Uprooting Lyme
Recover & Reclaim Program 2021

Please fill out all of the questions as thoroughly as possible. Upon receipt, we will reach out to you to schedule a phone or Zoom conversation to discuss the Recover & Reclaim program in more depth and to see if it’s a good fit for you. We look forward to getting to know you! 

Recover & Reclaim Confidential Application

Name *

Best Phone Number *

Best Email *

Street address *

City *

State *

Please describe in 3 paragraphs or FEWER your health as it is right now, including current diagnoses and symptoms. *

What are the 3 most important symptoms that you would like to heal that would have the greatest impact on your quality of life, and why are these important to you? *

What is currently holding you back from moving forward in healing from Lyme disease or complex chronic illness (for example, lack of knowledge, time, energy, clarity, money)? *

How do you hope we can help you? *

Please describe the other commitments do you have that might keep you from being 100% successful in implementing a holistic treatment program (to a job, your family, foreign travel, etc.)? *

On a scale of 1-10 (1 being “not at all”, 5 being “somewhat” and 10 being “100%!”), how ready are you to commit to working steadily to achieve your goals? *

1

2

3

4

5

6

7

8

9

10

Describe your current support system (family, friends, or social groups that can support your recovery process): *

Are you able to devote approximately $250-$400 a month ($75 for consultations + herbs or supplements at an additional cost) on recovering from your illness and achieving a state of health you may not previously have believed was possible? *

Are you open to making significant changes to your current diet and/or lifestyle if it means achieving that state of health? *

In a few sentences, tell me why you feel the Uprooting Lyme Recover & Reclaim Program may be right for you, and why now is the right time. *

Do you have any questions that you want to be sure we address when we speak in person? *

Please describe how you found us: *

Facebook

Referred by a patient

Referred by a friend

Google search / cruising the web

I just listened to an excellent free webinar

We met at a conference

Other

reCAPTCHA

Δ