First Name *

Last Name *

Phone

City

State

Email *

Tell us a little about yourself

Anything you’d like to share — family, work, hobbies, background, etc.

What made you want to be a guest on the show? *

If other, please explain

What have you tried so far to feel better?

What has been the hardest part about living with these symptoms?

If you could better understand ONE thing about what’s going on in your body, what would it be? *

Is there anything you feel afraid, nervous, or unsure about sharing publicly?

What would make this conversation feel meaningful for you?

How open are you to addressing pain and hormone challenges through nutrition and lifestyle-based strategies? *

Very interested

Curious

Unsure

Not sure yet

If our conversation uncovered something meaningful, would you be open to exploring next steps afterward? *

Yes

Maybe

Not right now

If you found a clear, personalized path forward, how ready would you feel to take meaningful action? *

Ready to take action now

Within the next 3 months

I’m interested but need more clarity

Just gathering information

Have you ever invested in a structured health or coaching program before?

Yes, and it was helpful

Yes, but I did not get the results I hoped for

No, this would be my first time

When it comes to investing in your health, who is involved in the decision?

I decide independently

I usually discuss it with my partner

I’m not sure

Do you know other women in their 40s or 50s who might resonate with this kind of conversation?

Yes

Maybe

Not right now

If yes, we’d love to invite them into this space as well. If you’re comfortable, you can share their name and email below, and we’ll reach out personally.

Referral 1 First Name

Referral 1 Last Name

Referral 1 Email

Referral 2 First Name

Referral 2 Last Name

Referral 2 Email

Referral 3 First Name

Referral 3 Last Name

Referral 3 Email

Are you comfortable being recorded and having your story shared publicly?

Yes

Maybe -- I'd like to talk more about it

No

I understand this and future conversations will be recorded and may be edited, published, and shared across podcast platforms and promotional materials. I give my permission for the recording to be used in podcast episodes and promotional material

I understand that this podcast is for educational and storytelling purposes only, and does not provide diagnosis, treatment, or medical advice?