Reset Detox Week Application

Name:

Age:

Are you eating any plant based foods or raw vegan foods currently? (Please select one)
YesNo

How would you describe your current state of health? (Please select one)
GreatAverageDealing with some health issuesFeel sick all the time

Please describe your typical day’s diet:

Have you done a juice fast or cleansing period / retreat before? If not, please state No, if YES, briefly describe what you did:

What are you hoping to achieve by attending the reset detox week?

Please list any current medical conditions. Please include such things as eating disorder, depression, anxiety, mental illness, drug abuse, alcholism, food allergies, heart disease, colon disease, blood sugar imbalance, etc if this applies to you:

Describe how you currently feel with your health, energy levels and mood:

Please list any current natural supplements or prescribed medication you are taking:

How committed are you to making changes to your health?

Thank you!

What’s next:

Your application will be reviewed, and if suitable, I will arrange a call to chat further with you to discuss next steps to securing your spot on Reset Detox Week in Bali.

Please leave your email address and phone number here:

Email Address:

Phone Number:

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