28 Day Support Programming Intake

October 5th Intake Form

Please complete. Your answers will grant Coach Kait a front row seat to your personal journey and help prep for your personal programming.

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Name:(Required)

Age:(Required)

How did you hear about POTS Strong?

Preferred email address:(Required)

Take a moment and summarize your current state of health/wellness in relation to POTS. Be specific. Include details.(Required)

Ex: I spend my days…I can- I currently can’t…

Having been diagnosed with Postural Orthostatic Tachycardia Syndrome, has your doctor prescribed exercise, nutrition and/or mindfulness as tools to manage symptoms? Summarize treatment & other forms of therapies.(Required)

Take a minute, close your eyes and visualize living POTS Strong™. What does that look and feel like?(Required)

Ex: improved orthostatic tolerance, manage blood volume, exercise 5-6 days/week, mindfulness techniques, I am understood, routine, my nutrition encourages proper circulation, energy preservation, heat tolerance, independence

What is your #1 motive to be POTS Strong™? Think of the reason you want this change. There may be many reasons; pick the TOP one.(Required)

What type of commitment are you able to offer towards your program?(Required)

1 Month

3 Months

6 Months

I am…(Required)

…ready to chat details! I’ll book my Take Action call myself. I see the option to book beneath this form. If I need alternate times I will email Kait at potsstrong@ko-wellness.net or DM via social. Looking forward to it!

October 5th Intake Form

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