CHK-IN with Jillian.

It’s all about checking in.
CHK-INs were designed as a way to keep the lines of communication open between visits so you can continue to receive feedback that promotes healing. Each client can decide the frequency of the interaction – daily, weekly or monthly. It can be as little or as much as you like./ Jillian Burne
CHK-IN
Fill in the REQUIRED FIELDS with your personal information. When completed, click on the SEND button to submit your information. You will receive a copy of the CHK-IN in your email.

Your Full Name (required)

Your Email (required)


I feel: (required)
 Better No Change Worse


List 3 success: (required)


List 3 concerns: (required)


I am: (required)
 Regular Constipated Loose Both


My energy is a: (required)
 1 2 3 4 5 6 7 8 9 10


My sleep is: (required)
 Improved No Change Worse


I fall asleep: (required)
 25% 50% 75% 100%


I stay asleep: (required)
 25% 50% 75% 100%


I drink this many ounces of water a day: (required)
oz.


I feel: (required)
 Hydrated Constantly thirsty


I'm following the diet: (required)
 Yes No


I'm taking all my supplements daily: (required)
 Yes No


I'm taking the following supplements: (optional)


I need help with the following 3 things: (optional)


At home Testing: (optional)
- pH Urine:
- pH Saliva:
- Zinc:  No taste Mild taste Bitter



I would like a 15 minute follow up conversation: (optional)
 Yes No

The best time to reach me between 10am and 2pm is: (optional)


Upload files (up to 3 files):



You will receive a copy of this CHK-IN in your email.

REVIEWING YOUR CHK-IN:

On my end, I review and make recommendations once a week on Friday between 10am and 2pm. If you need a quick 15 minute phone call to clarify an issue, just note the best time to reach you within that timeframe on your CHK-IN.