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Name*

Email Address*

Phone*

Where did you hear about Canna Bliss Wellness Coaching?*

What would you like to accomplish through this cannabis coaching program List everything you want to improve or achieve in your health and life DREAM BIG and paint the picture for me?*

What is your biggest health concern?*

Tell me a little more about what you have done in the past or are currently doing to help with this issue:*

What has proven effective:*

What is your current diet like? Please be specific list breakfast lunch dinner and snacks as well as the times you eat*

What would you like your health and life to look like 30 days from now How about 90 days from now How would you feel if you got this result*

What obstacles do you need to overcome to get this result*

Do you live where cannabis is legal for medical or recreational use?*

YESNO

Please describe your current cannabis use in detail times of day approximate dosage methods of ingestion*

What does cannabis help you with or what would you like to use it for: *

Have you experienced any negative side effects from cannabis? If so please describe:*

What questions do you have about cannabis?*

Are you ready to invest in yourself today?*

What are 5 things you LOVE about your life?*

On a scale of 1 to ______ someone super awesome how awesome are you*

Finally, Are you ready to start this journey and new beginnings?*

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Please fill out this form and provide as much information as possible. This will allow us to review your plan and guide you through your journey.