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Lisa Chapek Wellness Application
I'm so glad you're here.
This short application helps me understand where you are in your health journey and whether we're a good fit to work together. There are no right or wrong answers — just be honest. It takes about 5 minutes.
What's your name?
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What's your email address?
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How did you hear about me?
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How did you hear about me?
A
Instagram
B
Google
C
Friend or Family member referred me
D
I've been following you for a while
E
Other
What's bringing you here? Check everything that applies.
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What's bringing you here? Check everything that applies.
A
Digestive issues (bloating, constipation, IBS, reflux, etc.)
B
Hormonal imbalances (irregular cycles, PMS, perimenopause, etc.)
C
Fatigue or low energy
D
Skin issues (acne, eczema, rashes)
E
Anxiety, mood swings, or brain fog
F
Autoimmune or chronic inflammation
G
Weight that won't budge despite doing "everything right"
H
I just know something is off and I can't figure out what
Tell me more about what's going on. How long have you been dealing with this, and how is it affecting your day-to-day life?
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What have you already tried?
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What have you already tried?
A
Seen my primary care doctor (and didn't get answers)
B
Tried elimination diets or cutting out certain foods
C
Worked with a naturopath or functional medicine doctor
D
Taken supplements
E
Changed my exercise routine
F
Tried different medications or birth control
G
Spent a lot of time on Google trying to figure it out myself
H
I haven't really tried anything yet — I'm just starting to explore
What would life look and feel like if this was resolved? What's the outcome you're hoping for?
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What's been the biggest thing stopping you from getting support until now?
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What's been the biggest thing stopping you from getting support until now?
A
I didn't know where to start
B
I've had bad experiences with practitioners before
C
I wasn't sure if anything could actually help me
D
Cost has been a barrier
E
Life has just been busy
F
I wasn't ready until now
When are you looking to start?
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When are you looking to start?
A
As soon as possible — I'm ready now
B
Within the next 30 days
C
Within the next 1–3 months
D
I'm still exploring my options
Working with me is an investment in your health. My programs typically range from $300-3,000 Are you in a position to make that investment if we're the right fit?
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Working with me is an investment in your health. My programs typically range from $300-3,000 Are you in a position to make that investment if we're the right fit?
A
Yes — I'm ready and able to invest in my health
B
I'm not sure yet — I'd need to know more before committing
C
Honestly, cost is a real concern for me right now
Is there anything else you'd like me to know before we connect?
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Submit
