Consultation Request Form

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Welcome!

I'm so glad you're taking the first step toward healing with Elevate Restorative Wellness.

Please take a moment to fill out this brief form — it helps me get a better understanding of your story and how I can best support you in reaching your health goals.

✨ This is Step 1 of 2 in getting started. Once you submit this form, you'll be taken to a confirmation page with a link to schedule your session.

👉 Be sure to click that link after submitting — your appointment won’t be confirmed until you choose a time.

I’m honored to learn more about your goals and see how we might work together on your wellness journey.

What Is Your Name? *

What is your gender? *

Female

Male

When Is Your Birthdate? *

YYYY

What is your email address? *

What is your phone number? *

Have you ever served (or are currently serving) the U.S. Military? *

Yes, Active Duty

Yes, I have served at one point

Yes, Retired U.S. Military

No, but I have a family member that is active duty or has served in the U.S. Military

Required

How did you hear of Elevate Restorative Wellness? *

Please list any health conditions that you are currently struggling with. *

What are your main reasons for pursuing functional wellness treatment at this time? *

At Elevate Restorative Wellness, we prioritize your well-being by offering self-pay services.

This allows us to provide personalized care without the limitations of insurance — so you receive the focused, root-cause support you deserve.

We’ll go over available packages and pricing together. HSA/FSA cards are accepted upon request.

This model gives you full transparency and control over your care — no surprises, just real partnership.

Yes, I understand and I’m open to investing in my health.

No, I’m not ready to invest at this time.

Awesome — you're making an empowered choice. 💪

✨ As a Reminder

This form is Step 1 of 2 in connecting with me.
Once you complete and submit the form, you'll be directed to a confirmation page with a link to schedule your appointment.

👉 Be sure to click that link after submitting—your session won’t be booked until you choose a time.

I’m excited to learn more about your goals and see how I can support you on your wellness journey.

Yes, I understand that I need to click the link on the following page to schedule my appointment

Required

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