YES! I want to discover and resolve the root cause of my health issue! Here's my application...

YES! I want to discover and resolve the root cause of my health issue! Here's what I understand so far about my situation...
The first step in me helping you is to gain some essential background.

The 5 minutes it will take you to fill in this form will be invaluable and enable me to know our next best step.

Rest assured all details are completely confidential and for my eyes only.

Here's to your transformation! :)

Kim
Personal Details
Name *

First Name Last Name
Occupation *
How did you hear of Kim Knight Health? *
E-mail *
Skype
If no skype, put 'none'
Landline Phone Number

- Area Code Phone Number
Cell Phone Number

- Area Code Phone Number
Country and time zone *
Age *
Your Situation
Tell me about the health issue you would like help with *
Complete the following statement: "I haven't felt well since..." or "things haven't been right since"... *
How is your life currently limited as a result of what you are experiencing? *
What would your life look like if this issue was resolved? *
As far as you currently know, what is currently preventing you from resolving this issue? *
As far as you currently understand, what do you think causes chronic illness or physical symptoms? (there is no right or wrong answer!) *
What will it cost you (energetically, emotionally, energetically, financially) to stay where you are 6, 12 months, 5 years... from now)? *
On a scale of 1-10 how ready are you for a breakthrough in your situation? *

If applicable, please tick if you have been diagnosed with, or suspect you may be experiencing, one or more of the following health conditions:

	Diagnosed by a doctor	Suspect I may have it	Unsure	Not applicable
Chronic Fatigue Syndrome (CFS)
ME (Myalgic Encephalomylitis)
Adrenal Fatigue Syndrome
Post Viral Fatigue Syndrome
Fibromyalgia Syndrome
MS Multiple Sclerosis
Irritable Bowel Syndrome
Anxiety
Depression
Insomnia
Other (see below)

Please note any other symptoms or health condition not listed above...
What other approaches or therapies have you already tried and what difference have they made? *
Working with Kim is a deeply powerful and positive transformational experience. Are you ready to create positive, lasting change in your life? *

Absolutely 100% Unsure Not yet
Are you ready financially and emotionally to invest in the personal support and guidance of a coach? *

Yes No
According to the insurance industry the average human life is valued at $9.1 million dollars. What value do you put on getting your health and life back? *

Less than $1000 $1000 - 3000 $3000 - 6000 $6000 - $10,000 Whatever it takes
Is there anything else I should know before we take the next step?
Thank you so much for taking the time to share this information. I will be in touch very shortly by email.

In the meantime, you can:
- check out useful videos on my youtube channel
- read handy articles on my blog .
- listen to weekly podcasts on my ITunes show
- join me on Facebook for the latest news
- sign up to my enews for the latest special offers
Cheers! Kim
Should be Empty:

YES! I want to discover and resolve the root cause of my health issue! Here's what I understand so far about my situation...