Request for Concierge Wellness
Thank you for reaching out. Please answer the questions below so we can get you started with the right plan ASAP. Your therapist will be in touch shortly.
Email address *
First & Last Name *
Your answer
Age
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Phone Number
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Which is the best way to get in touch with you? *
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How did you hear about us? *
What services are you interested in? *
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Please initial below that you have read and understand the following: Patricia Fasciotti Wellness is does not accept/is not in network with any insurance plan. We accept cash, check/zelle, credit, venmo/applepay/paypal, HSA/FSA cards for payment. *
Your answer
Briefly describe your current struggles/goals *
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What is this problem preventing you from doing in life that you want/need/love to do? *
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Have you seen a Physician or other complementary service provider for this? (chiropractor, massage therapist, etc) *
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Briefly describe that experience
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Why is now the time to take action? *
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Do you or have you ever experienced any of the following? *
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We provide services in your home, will that work for you?
Briefly share any other questions or concerns
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