Getting to know you
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What is your name (please include first and last names) 

What email address may we use to contact you? 

I’d love to know where you are located.  What city or town do you currently live in?

Are you filling this survey out for yourself or on behalf of someone else?
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What are your main goals for seeking nutrition counseling with DaKare Wellness Centre? (select all the apply)

I’d love to know how you found me or who referred you? 

Do you have any known health or medical conditions or diagnosis that we should know about in helping you to find the best care? If yes, please explain. 

What have you tried so far to address your goals?  (Diets, testing, etc.)    

Which of the following items are currently in your diet in any amount: (select all that apply)

What percentage of your meals are currently home cooked? 

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Please let me know anything else about you, your goals for nutrition counseling with DaKare Wellness Centre or your health aspirations.  

I am committed to working with individuals who are dedicated to their health and ready to receive support on their individualized journey to health and healing.  In two to three sentences, tell us something about yourself and/or your health history that will help us to get to know you before we take any further steps to dig more deeply into the details of your concerns.  When you are done, we will schedule your complimentary 15-20 mins Strategy Session. 

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