Brain Fog Bootcamp: Thyroid Edition "*" indicates required fields Name* First Last Email* Phone*What state do you live in? Type inHave you been diagnosed with hypothyroidism?*YesNoSelect oneIf yes, have you been diagnosed with Hashimoto's?*Yep, that's me!No, I do not have Hashi'sUmm... what?Select oneIf you could magically change 3 things about how you currently feel, what would those be?*What is the biggest thing you hope to achieve in this program?*Do you have any confirmed medical diagnoses? If so, please list below. (This is confidential! It is really important that I know as much about you as possible!)*Are you on any medications? If so, please list below.*What supplements are you taking?*Are you currently under the care of a medical doctor/provider?* This is not a weight loss course, but weight changes can (and do) occur as the result of implementing what you'll learn.Aw, shucks. Really just want weight loss.Totally fine. Weight changes would be great, but not main goal.Not concerned at all. Just want my brain back.Select oneHow would you describe your relationship with food currently? What about in the past?* Do you currently or have you ever had an eating disorder or disordered eating?* On a scale of 1-5, how motivated are you to make major changes in your diet and lifestyle to achieve your goals? (5 being the most motivated)*Please enter a number from 1 to 5.Thank you so much for applying!!!We'll be in touch really soon 🙂 Looking forward to working together! NameThis field is for validation purposes and should be left unchanged.