Plant-Based Gut Master Method Program - Application

At Aysa Nutrition, I work to ensure that my patients are a well-placed therapeutic match for my programs and services. Please use this application to tell me more about yourself, your pain points, and your digestive health goals. 

After submitting this application, you will be directed to my personal calendar, where you will schedule a 15-minute consult with me to review the results of your application and discuss next steps. 

Full Name + Pronouns 
E-mail
Phone Number
State/Region (where you currently live) 
Have you been diagnosed with IBS, IBD, GERD, SIBO, or another gastrointestinal condition by a physician?

*Please indicate with a YES or NO

*If yes,Please indicate your diagnosis. 
*What testing was done to reach your diagnosis?
*What methods or medications have you tried to manage your condition?

*What has worked for you and what hasn’t?
Are you actively struggling with, or in recovery from, an eating disorder? 
If you could transform your digestive health in 3-6 months, what are the top 3 changes you would hope to see? How would your life be different? How would you feel?
Are you more interested in one-on-one OR group nutrition counseling?
On a scale of 1 to 5 (5 being the most committed), how committed are you to getting in control of your unpredictable bloat, brain fog, and bowel habits?
I offer flexible payment options to work with me. If I can provide you a roadmap to gain clarity and control over your bloat and bowel habits, and you’re a good fit for my program, are you ready to make a deposit to get started on your transformation?
Program investments range from $499 to $999 charged monthly over the minimum 1:1 or group program duration. I accept HSA and FSA payments and can provide a superbill, but I do not accept insurance at this time. Please acknowledge below.
Yes*
No
Yes
No
One-on-One
Group
Both
I'm not sure
1
Yes
No
Got It!

Note: Please place an "X" in the corresponding box

Note: Please place an "X" in the corresponding box

2
3
4
5
Least Committed
Most Committed

Note: Please place an "X" in the corresponding box

Note: Please place an "X" in the corresponding box

Note: Please place an "X" in the corresponding box

Note: Please place an "X" in the corresponding box

*Please indicate with a YES or NO

*Please indicate with a Number 1-5

*Please indicate with a YES or NO

*Please indicate with a YES or NO

You've successfully submitted your Application

Congratulations! You've successfully submitted your application. There’s only one more step to complete the process.



Please select a date/time in the next week to discuss the results of your application review.


 During this call, you will have the opportunity to share any other details you’d like with me regarding your digestive health journey, and I will let you know whether my programs and services are a good therapeutic match for your goals, and which services will best serve you. 

Note, the small fee associated with this call is to honor our allocated time together, as well as the time of other current and prospective clients. A refund can be issued if cancellation is requested >24h in advance of the session but will not be issued otherwise.


Thank you for Scheduling your Consultation Call
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