Getting to know you!
We are so excited to get to know you and partner with you on your journey toward optimal health. Please take just a moment to get to know us and allow us to begin getting to know you. Talk to you soon!
Name (First and Last)
Are you a current Wellness+ member?
Not yet but plan to join soon.
Not a member and have no immediate plans to join.
Wellness Consultant Shared Information Acknowledgment
This information will be shared with our Wellness Director and will then be used to select a Wellness Consultant that best suits your needs. If you are not comfortable with this, please do not fill out this form. Thanks!
Prefer not to say
Do any of the following apply to you?
El español es mi idioma preferido. (Spanish is my preferred language)
Seeking gender specific services.
None of the above apply to me.
Referred by a community practitioner (please include who in the following question)
Please describe why you want to meet with a Wellness Consultant. Please be as thorough as you wish.
Are you currently under the care of any medical professional (dietician, doctor, psychologist, nutritionist)?
If yes above, please describe.
Please list any current and past medical diagnoses that you are comfortable discussing.
A copy of your responses will be emailed to the address you provided.
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