Fall 2026 Cohort Registration

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What is your name?

What is your email?

What is your country code and phone number ?

What is your age?

Which country do you live in?

Please list any medications you are taking, if any.

Please list any herbal supports or supplements you are taking, if any.

Please check the boxes next to substances you consume regularly.

Cigarettes / Smoking

Alcohol

Caffeine

Please list any other mind or mood altering substance(s) you take, if any.

Please list any surgeries or major medical procedures you have had, if any.

Please list all food/medical allergies, especially black walnut.

Please list any food or environmental factors that trigger you to have an inflammatory (swelling, redness, pain) or histaminic (itching, flushing, hives, congestion) reaction.

Are you pregnant or breastfeeding?

Have you had any root canals?

Have you had any vaccines? If yes, feel free to list them (especially any recent ones).

Do you have any medical diagnoses (past or present), or are you experiencing any unique symptoms you feel I should be aware of?

Do you have a history of recurring infections? (UTI, bladder, sinus, yeast, etc.)

Are there any current events, stressors, or dynamics in your home or personal life that may be affecting your emotional well-being at this time? If so, please share anything you feel comfortable with.

How connected do you feel to your spiritual or inner self these days? Feel free to skip if this doesn’t resonate.

What do you hope to gain through this container?

Are you currently following any specific style of eating? (For example: keto, vegan, raw vegan, carnivore, gluten-free, etc.)

Describe your typical breakfast.

Describe your typical lunch.

Describe your typical dinner.

Describe your preferred snacks.

I offer three tiers of supplement suggestions, ideal, moderate, and budget-friendly, so this work can remain effective while meeting you where you are financially. Monthly costs will naturally fluctuate depending on what we’re working on, what your body needs at that time, and shipping. Please select an average budget you’d like me to work with.

If you have a more comfortable monthly budget, please record it below.

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Registration Form

Your responses are confidential and will support me in building a personalized protocol for your journey

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