Expression of Interest Form

Welcome! I’m so glad you’re here. 🙌 It sounds like you’re ready to make changes so you can feel great — day after day, year after year. That’s AWESOME. Let’s get started!

This quick form will help you clarify your goals and commitment, and it will help me see if I’m the right person to support you. My top priority is making sure you have the best chance to succeed.

I’m excited to connect and support you in making major shifts in your wellbeing!

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Nadya Tkachenko Holistic Health Pro and Habit Consistency Coach Founder and Facilitator of "Live & Thrive Wellness" and the Holistic Health Accelerator Program

First Name

Last Name

Email Address

Your Age Range

20-30

30-40

40-50

50-60

60-70

70-80

Did someone refer you?

Challenges, Vision, Goals

What are the 1-3 MAIN CHALLENGES that you are currently facing around your health and your habits?

What are your TOP 3 GOALS or breakthroughs that you want to experience around your mind-body health and your habits in the next 3-6 months?

Let's get more specific with your objectives. What do you want?

Check all that apply:

Let's get more specific with your objectives. What do you want?

I want to take better care of myself

I want to become more consistent with healthy habits without relying on willpower

I want to eat more mindfully or eat a healthier diet

I want to sleep better

I want more energy or more stable energy

I want to gain tools for dealing with stress and overwhelm

I want to have fewer cravings

I want to feel and look younger

I want my weight to be different

I want to clear my issues with digestion and / or elimination

I want to feel more present and connected to self and others

I want to experience less negative self-talk and practice more self-compassion

I want to resolve or reduce the symptoms of my chronic health issues (details below):

What do you think has kept you back from reaching your goals or resolving your challenges?

I have trouble prioritizing myself

I know what I should do by I can't stay consistent

My peers don't have the same goals or habits

I've tried to go it alone / I haven't invested in the right support

I've tried various solutions but never truly invested in up-leveling my health

I haven't made health evolution into a fun process or game

None of this applies to me

Why is NOW a good time to make changes?

How ready are you to make real changes in your health trajectory?