Mind, Body & Soul Wellness Intake Form
Get ready to inhale success and exhale the stress at The Pole Point Fitness & Wellness Studio! 

We are beyond excited to provide a transformative and goal-oriented approach to your personal growth. Together we will help you navigate challenges, improve self-confidence, and unlock your full potential. There are a variety of services we will roll out and this form seeks to learn more about you and figure out which modalities are best suited. 

We specialize in success coaching, dramatic arts therapy, and somatic healing practices like breathwork and Chi Gong. You will have the option of choosing between having in person sessions or online sessions. 

Intended hours: Monday - Saturday from 10am-6pm outside of class times from the Fitness Division.

Please complete the form below to be added to the wellness waitlist.
Sign in to Google to save your progress. Learn more
Email *
First Name *
Last Name *
Date of birth *
MM
/
DD
/
YYYY
WhatsApp Contact Number *
Contact info
Are there any specific services you are interested in starting? *
Required
Have you ever worked with a therapist before? If yes how was the experience? *
Have you ever worked with a life coach before? If yes how was the experience? *
Have you ever taken a breathwork or mindful movement class before? *
What do you hope to get out of your sessions? *
Do you have any medical conditions? If yes, what? *
Have you had any surgeries? What and when? *
Have you had any injuries? What and when? *
Allergies or dietary restrictions? *
Required
If Other was selected, please specify. *
Would you like to subscribe to our newsletter to learn more about our classes, offerings, promotions and other special events? *
Got a Gift Certificate? Type in the number here 
What happens after I submit this form?
We will contact you via our email polepointfitandwell@gmail.com to share our booking app so you can reserve your spot for each class. We will also confirm how to dress and answer any other questions you may have.

Thank you,
The Pole Point Team
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report

Google Forms