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Welcome to New Hope Health and thank you for your interest in participating in our Virtual Detox Program.

Please provide the information below. You will receive an email notification if approved.

First Name *
Last Name *

Phone *

Email *

8 Brief Questions to Apply:

1. Are you a current client with New Hope Health? *

YesNoNot Sure

2. How did you hear about the Virtual Detox program? (I am a current NHH client, Referred by a current NHH client, Facebook, NHH Newsletter, Other-Please explain) *

3. Would you commit to helping Dr. LeAnn and the New Hope Health team continue to deliver the best programs available by taking a brief survey at the end of your program? (It will only take about 10 minutes or less) *

YesNo

4. What are your top 3 health concerns? *

5. Do you have any diagnosed conditions (diabetes, high blood pressure, etc)? *

YesNo

If so, list them here.

6. What is your primary reason for wanting to do this detox? *

7. Have you been excessively ill lately? *

YesNo

8. Are you taking more than 2 medications? (This isn’t an automatic deal breaker) *

YesNo

Other

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