Wellness Questionnaire

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Please fill out the form so I know your health goals and challenges. Looking forward to chatting more and seeing I can help you.
Kate

Instagram or Facebook Name *

Name *

Phone *

Email *

Which describes you best? *

I'm Stressed out and not taking care of myself. I know I need to change, but don't know where to start!

I start things and then stop. Consistency is my downfall and I need someone to hold me accountable on my health journey.

I'm pretty on point with my health, but my kids are fussy eaters and I'm finding it hard to know what to do to support them.

I'm dealing with health challenges that I know I cant ignore anymore and am ready for change.

I'm really happy with where my health and wellness is at, but am always looking to improve and be around like minded people.

What would you say would be one or two areas of your health that you would love to see improvements in? *

Have you ever done a detox before? *

Never

Years ago

Yes I detox once a year

I detox 3-4 times a year

Required

How active would you say you are? *

I dont exercise

1-2 times a week

3-4 times a week

I move my body daily and I can't get enough

Required

What are some habits that you would like to kick? *

I'm a sugar addict

Coffee is my crux

I can't stop eating chocolate

I eat pretty much anything when I'm stressed

I work so hard and don't ever make time to exercise and eat well

Putting the kids health and wellness ahead of my own

Procrastination, I always say I will start tomorrow

Smoking, its time to kick this habit!

Drinking is my go to and I know its not helping me with my goals

Take away food

Other:

Required

What is the weekly budget you can put aside to invest into your health goals? *

Are you committed to achieve your goals? *

Absolutely!

I think so, I just have some questions first

No, I'm happy with where I'm at and don't want to change.

Thanks for much for taking the time to share a little about yourself. I will be in touch to chat more and see how we can help you reach your goals. Kate

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