14-Day Detox, 1-Month Program
Indicates required field
Email and Phone Number
Please enter the best email and phone number. Much of the program communication is done via email, so make sure this is an account that you check regularly.
All participants must enroll in the 1-month online detox program ($50)
Additional program features are listed below. Please select any and all that you would like to add to your program.
14-Day Detox: Program Selections
14-Day Detox Program *required ($50)
45-Minute Individual Coaching Session - Program Start (+$75)
45-Minute Individual Coaching Session - Program End (+$75)
45-Minute Group Coaching Session (3-5 people)- Program Start; please have all members of your group register separately. (+$15)
45-Minute Group Coaching Session (3-5 people) - Program End: please have all members of your group register separately. (+$15)
If registering as a group, please enter the names of the other group members here.
List all group members here, but please make sure all members fill out a separate registration form. Thank you!
Please indicate your desired program start date below.
(1) Your detox start date will automatically be 1 week after your program start date.
(2) If you have indicated that you would like to include a coaching session (individual or group) at the program start, please visit my
and choose your appointment time. The appointment should take place sometime during the first week of your program, or prior to your detox start date.
Desired Program Start Date:
Payments may be made via check to:
Kia Nesmith, Simply Wellness
P.O. Box 624
Three Rivers, CA 93271
Or via credit card invoice (Visa, MasterCard, American Express, Discover). An invoice will be emailed to you, and payment is due prior to or at the time of your first coaching session. Any additional payments will be due prior to or at the time of your subsequent coaching sessions.
Once submitted, you will be taken to the scheduling page where you can select your start date by choosing the date and time for your first coaching appointment. If you are unable to find a time that works for you, please contact me directly at firstname.lastname@example.org or (831) 600-6091.
By clicking the button below, I hereby commit to invest in
and detox from sugar! I agree to the payment amount and terms selected above. I understand that I have 1 week from today's date in which to cancel or withdraw from the program for a full refund
(minus a $5 processing fee)
. After that time, I understand that I will be responsible for the entire financial commitment. I understand that a space is reserved for me and preparations are made for my participation in the entire program immediately upon my registration.
Thank you! I look forward to serving you.
I agree to receiving marketing and promotional materials
Sign Me Up!
Create your own unique website with customizable templates.