Drs Referring Mom Q Form

Reboot 3.0^TM

My Reboot 3.0^TM system is not for everyone.

The questions below will help determine if you qualify.

If you don't, I'll still provide you with a powerful harm reduction strategy, at no cost** to you!

** and only ask that you provide me with your personal feedback.

For your safety and for maximum effectiveness, I'd like to collaborate with your health care provider while you're taking this course or in one-on-one coaching.

Yes, you have my permission. Please send me the appropriate Consents & Releases by email before I begin.

No, I'd prefer not; you do not have my permission. I feel confident in doing this on my own and take full responsibility for doing so.

I believe smoking / vaping is

mostly an addiction

mostly a habit

both a habit + addiction

a habit and addiction AND MUCH MORE

If you had to choose ONE, what's your #1 "go-to" source about HEALTH and WELLNESS, or quitting smoking / vaping?

Science

Less from science; more from "what works" wherever it comes from

My friends

Inernet

Other (please describe in the question marked with a ** below)

One-on-one transformational health coaching requires a commitment of some time, and a financial investment. I'm...

100% committed - both my time AND financial investment.

able to commit MOST days.

not sure where I stand or what I want right now but I want to explore health coaching.

Will you want personal coaching? This is limited to 5, max., and requires a significant investment.

No thanks

Yes, definitely

Maybe

ALL members of my household will

be 100% supportive of my commitment to Nico transformational health coaching

be LESS THAN 100% supportive

be neutral - neither supportive or unsupportive

I'm the only one in my household

I understand the information collected in this form complies with the EU's GDPR

50% Complete

Two Step

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Reboot 3.0TM

My Reboot 3.0TM system is not for everyone.

The questions below will help determine if you qualify.

If you don't, I'll still provide you with a powerful harm reduction strategy, at no cost** to you!

Two Step

Reboot 3.0^TM

My Reboot 3.0^TM system is not for everyone.