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Can We Work Well Together?
First Name
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Last Name
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Email
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Lifestyle
I am willing to modify my lifestyle in order to improve my health.
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I strongly agree
I somewhat agree
I neither agree nor disagree
I somewhat disagree
I strongly disagree
I am willing to abstain from foods and food-like substances which may be destroying my health, wellness and longevity.
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I strongly agree
I somewhat agree
I neither agree nor disagree
I somewhat disagree
I strongly disagree
I am willing to eat healthy foods which can improve my health, wellness and longevity.
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I strongly agree
I somewhat agree
I neither agree nor disagree
I somewhat disagree
I strongly disagree
I am willing to trust that my desires for destructive foods and behaviors will decrease.
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I strongly agree
I somewhat agree
I neither agree nor disagree
I somewhat disagree
I strongly disagree
I am willing to trust that my desires for healthy foods and behaviors will increase.
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I strongly agree
I somewhat agree
I neither agree nor disagree
I somewhat disagree
I strongly disagree
Methodology
I prefer to find and implement a natural, holistic remedy when possible instead of pharmaceutical treatment of symptoms.
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I strongly agree
I somewhat agree
I neither agree nor disagree
I somewhat disagree
I strongly disagree
I am willing to have my genetics tested and revealed to my primary psychiatrist, psychotherapist or primary care doctor in order to create a precise, customized plan for my health journey.
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I strongly agree
I somewhat agree
I neither agree nor disagree
I somewhat disagree
I strongly disagree
Collaboration with Team
I am willing to learn and comply with the natural, integrative approach to my care.
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I strongly agree
I somewhat agree
I neither agree nor disagree
I somewhat disagree
I strongly disagree
I am willing to fully collaborate in the thorough assessment including completing long questionnaires to enable my doctor to be prepared in advance of my appointments.
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I strongly agree
I somewhat agree
I neither agree nor disagree
I somewhat disagree
I strongly disagree
I am willing to be completely honest and forthright with my Dr. Harrell and her staff, especially regarding any medications, supplements or illicit substances I have used or am currently using.
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I strongly agree
I somewhat agree
I neither agree nor disagree
I somewhat disagree
I strongly disagree
I am willing to arrive at my appointments at or before the scheduled time.
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I strongly agree
I somewhat agree
I neither agree nor disagree
I somewhat disagree
I strongly disagree
Financial
I am willing and able to invest financially in my health, wellness and longevity with cash, credit card, since the practice does not process or take insurance. I am prepared to pay for services at check-in.
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I strongly agree
I somewhat agree
I neither agree nor disagree
I somewhat disagree
I strongly disagree
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