Here’s What To Do Next
If you believe Functional Holistic Coaching is what you need to transform your health and wellness, then please fill out the short application form and you'll be able to schedule a time for us to talk :)

In that time, I'll review your application to make sure I'm a good fit for your needs. If you meet the requirements, we will continue with your scheduled call time.

If I feel that I would NOT be a good match to help you, I'll send you an email and give you resources that will point you in the right direction. Either way, you're going to get a game plan on what to do in order to begin your healing journey.
MAIN HEALTH CONCERNS
What's the #1 health complaint you have?  Be as descriptive as possible, including severity of your symptoms.
How long have you been suffering from these symptoms?
How have you dealt with these concerns in the past?
Have you experienced any success with these approaches?
NUTRITIONAL STATUS
Which of the following foods do you consume regularly? soda, diet soda, refined sugar,alcohol, fast food,gluten (wheat, rye, barley), dairy (milk, cheese, yogurt), coffee
Are you currently on a special diet? autoimmune paleo (AIP), SCD/GAPS, dairy restricted or dairy-free, vegetarian, vegan, paleo, blood type, raw, refined sugar-free, gluten-free, Other (please describe)
 What percentages of your meals are home-cooked?
Is there anything else I should know about your current diet, history or relationship to food?
Other
Please describe any other information you think would be useful in helping to address your health concern(s)
What are your health goals and aspirations?
Contact Information
  I take privacy and confidentiality very seriously.
Your information is 100% secure and will not be
sold or shared with anyone.
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Maritza's MediZen Disclosure Statement:
This website and its contents are for informational purposes only. It is not intended to treat, diagnose, cure, or prevent disease. This report has not been reviewed by the FDA. Always consult with your primary care physician, certified nutritionist or doctor before making any significant changes to your health and wellness routine.
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