Apply to Work with Nurse Coach Katherine - Chronic Wellness Collective

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Tell me about yourself


How old are you? {"type":"text","name":"Age","width":10,"value":"","size":"Normal","validation":"TN","validationMessage":"Please enter a number.","placeholder":""}

     What time zone are you in? {"type":"text","name":"__generic","width":30,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","placeholder":""}



How did you learn about us?
{"type":"text","name":"__generic2","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","placeholder":""}




If a person referred you, please type their name below.{"type":"text","name":"__generic3","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","placeholder":""}



What is the name of the Coach you are applying to work with? {"type":"text","name":"__generic","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","placeholder":""}



What is your biggest health concern or challenge right now?{"type":"textarea","name":"__generic4","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","height":80,"placeholder":""}



What seems to be the biggest obstacle to better health?{"type":"textarea","name":"__generic5","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","height":80,"placeholder":""}



What symptoms bother you the most?{"type":"textarea","name":"__generic6","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","height":80,"placeholder":""}



What have you already tried for these symptoms? Did it help?{"type":"textarea","name":"__generic7","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","height":80,"placeholder":""}



How does it feel to still not have relief from your symptoms?{"type":"textarea","name":"__generic8","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","height":80,"placeholder":""}



What is the #1 desired outcome you would like to accomplish in the next 6 months?{"type":"textarea","name":"__generic9","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","height":80,"placeholder":""}



What do YOU believe is the root cause of your symptoms?{"type":"textarea","name":"__generic10","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","height":80,"placeholder":""}



Tell me about your health beliefs


Have you worked with a coach or mentor before? YesNo{"type":"select","name":"__generic11","width":20,"value":"","size":"Normal","validation":"N1","validationMessage":"Please make a selection for this item.","options":"Yes\nNo"}

     


What was that experience like for you?{"type":"textarea","name":"__generic12","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","height":80,"placeholder":""}



From 1-100%, how responsible do you feel for your own healing? 12345678910{"type":"select","name":"__generic13","width":20,"value":"","size":"Normal","validation":"N1","validationMessage":"Please make a selection for this item.","options":"1\n2\n3\n4\n5\n6\n7\n8\n9\n10"}

  • 1 meaning you don't want to be uncomfortable and you're not willing to make any changes to create the result that you want. 
  • 10 being that you know shifting old patterns can be uncomfortable but understand that its necessary to heal and are willing to do it. 


Are you willing to put your healing and the work that is required for your healing as a priority in your life? (This means you will need to spend 30-90 minutes a day on your healing.) Yes, I'm ready.No, I don't think so.I'm not sure.{"type":"select","name":"__generic14","width":40,"value":"","size":"Normal","validation":"N1","validationMessage":"Please make a selection for this item.","options":"Yes, I'm ready.\nNo, I don't think so.\nI'm not sure."}

 


Are you open to the idea that physical ailments have an emotional connection? YesNoMaybe{"type":"select","name":"__generic15","width":30,"value":"","size":"Normal","validation":"N1","validationMessage":"Please make a selection for this item.","options":"Yes\nNo\nMaybe"}




What would be the length of time that you are willing to invest in your healing? {"type":"checkbox","name":"__generic16","width":100,"value":"","size":"Normal","validation":"C1","validationMessage":"Please check at least one item.","options":"1 month\n3 months\n6 months\nWhatever it takes"}




What kind of solution are you looking for right now?{"type":"radio","name":"__generic17","width":100,"value":"","size":"Normal","validation":"C1","validationMessage":"Please choose one of the above options.","options":"DIY Solution (money is tight & I'd rather learn and do it myself)\nDone WITH me solution (do it myself with the guidance of a coach)"}


What are the biggest reasons you're drawn to working with a coach versus healing on your own? {"type":"textarea","name":"__generic18","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","height":80,"placeholder":""}




Financial Aid



How many hours a week do you work outside the home (paid employment only)? {"type":"text","name":"__generic19","width":30,"value":"","size":"Normal","validation":"TN","validationMessage":"Please enter a number.","placeholder":""}




From whom do you receive financial support? {"type":"text","name":"__generic20","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","placeholder":""}



Are you currently caregiving for children, aged parents, or other dependents? If so, for whom? {"type":"text","name":"__generic21","width":70,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","placeholder":""}




In the past year, how much have you spent out-of-pocket on alternative healthcare (such as chiropractors, massage therapists, functional medicine doctors, nutrition coaches, etc.)? {"type":"text","name":"__generic22","width":40,"value":"","size":"Normal","validation":"TN","validationMessage":"Please enter a number.","placeholder":""}




How much debt do you currently carry? How much of this debt is related to medical expenses? {"type":"text","name":"__generic23","width":40,"value":"","size":"Normal","validation":"TN","validationMessage":"Please enter a number.","placeholder":""}




Would you be interested in financial aid if it is available (such as an extended payment plan, partial scholarship, etc.?) YesNoMaybe{"type":"select","name":"__generic24","width":30,"value":"","size":"Normal","validation":"N1","validationMessage":"Please make a selection for this item.","options":"Yes\nNo\nMaybe"}



May we inform you by email if you've been accepted? YesNo{"type":"select","name":"__generic26","width":30,"value":"","size":"Normal","validation":"N1","validationMessage":"Please make a selection for this item.","options":"Yes\nNo"}



By checking one or both of these boxes, you give us permission to contact you electronically. We are using this for internal purposes only.
{"type":"checkbox","name":"__generic25","width":100,"value":"","size":"Normal","validation":"C1","validationMessage":"Please check at least one item.","options":"I consent to being contacted by email."}