Request edit access
JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
DIWS Membership Application
Building a TRIBE means meeting the needs of all our members. The information provided here will help me know how to provide our community with the best and most needed information.
* Indicates required question
Name
*
Your answer
Address
*
Your answer
EMAIL
*
Your answer
Phone number
*
Your answer
What types of relaxation practices have you tried?
*
Meditation
Prayer
Journaling
Yoga
Aromatherapy
Music
Visualization
Exercise
Other:
Required
What types of things are you interested in?
Career/Life Purpose Wellness
Family Facilitated Events and Wellness
Financial Wellness (Financial Planning/budgeting, Insurance)
Health and Fitness (Nutrition, Exercise)
People with Fur Family Wellness (Pet loving human Centered Wellness)
Reiki
Relationship Wellness (Partner, Parenting, Adult Child Caregiver, Friends and Peer connections)
Stress Management (Relaxation Practices, Meditation, Fiber Arts)
Wellness Topics (Aromatherapy, meditation, creative writing, fiber arts, etc )
Anything else important for us to know?
Your answer
I authorize, you to contact me and provide me with a complimentary telephone consult. I realize that this telephone consult does not replace formal therapy or professional nutritional advice. I am aware that I will be able to schedule follow up counseling/coaching and that these services may be reimbursed through my insurance carrier.
*
By checking this box you acknowledge reading the above statement.
Required
BY CHECKING THIS BOX BELOW YOU WOULD LIKE TO RECEIVE OUR DIWS NEWSLETTER OR SPECIALS
*
YES I absolutely love wellness topics and offerings
Not right now my inbox is overflowing
I'd prefer to learn about them through social media posts please add me to the DIWS page.
Required
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Report Abuse
-
Terms of Service
-
Privacy Policy
Forms
