THE WELLNESS SURVEY 2023

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You are here because you want to have tools to create lasting shifts in your life; make changes in your body, so you can feel great day after day, year after year, and have constant access to your energy and vitality? Okay, let's get on it.*

Once you've completed this brief form, you'll be taken to a page with a scheduling link - after you schedule a call, we can chat!

*Please note that all responses are confidential.

Email *

First & Last Name

Your Phone Number

Let's start by finding out where you are today. Check all that apply. Be honest with yourself: *

I am tired

I am too busy

I don't feed myself as well as I should

I am heavy

I don't sleep well

I have a lot of anxious thoughts and feelings

I tend to feel moody or depressed

Anything specific you want to add to the above items?

Tell me more about you and your life.

I feel stuck in my personal life

I feel stuck in my professional life

I feel stuck in my spiritual life

I have a hard time setting boundaries

I have a passion for what I do

I balance care for others with care for myself.

I am aligned with my deep purpose

I am fully connected with my loved ones

I have enough time outside of work to do the things I love

Anything specific you want to add about the items above?

To create a constant state of being Energized and to Thrive is about applying tools to shift and having habits for living your best life. What do you want?

Column 1

I want to eat a healthier diet.

I want to have more energy.

I want to prepare food for myself more often

I want to meditate (or more consistently) OR even learn how to.

I want to take better care of my skin, my eyesight and or my hearing.

I want more emotional balance.

I want more mental clarity.

I want to be able to speak my mind freely without fear.

I want to have better relationships and boundaries.

Column 1

I want to eat a healthier diet.

I want to have more energy.

I want to prepare food for myself more often

I want to meditate (or more consistently) OR even learn how to.

I want to take better care of my skin, my eyesight and or my hearing.

I want more emotional balance.

I want more mental clarity.

I want to be able to speak my mind freely without fear.

I want to have better relationships and boundaries.

Clear selection

Anything specific you want to add about the items above?

I could really use support around: *

My biggest health challenge is: *

If you really knew me, you would know that... *

I want to have the following mental/emotional/physical health breakthroughs in the coming year (take a pen to paper & spend some time with this) *

What's your current level of commitment to accessing these mental/emotional/physical health breakthroughs? *

Limited, I'm just exploring

Absolutely 100% committed.

Please schedule your discover session by clicking on the link below. I can't wait to speak with you! Thank you!

https://calendly.com/romyoga

How did you hear about this immersion? If you heard about this from a friend, please share the name and contact information so I can thank them personally. THANK YOU FOR MAKING THE TIME TO COMPLETE THIS FORM! *

A copy of your responses will be emailed to the address you provided.

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