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Customized Wellness Plan
Create Your Personal Wellness Plan
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Email
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Your email
Preferred Name
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Your answer
Preferred Pronoun
Your answer
How would you rate your health
Extremely Poor
1
2
3
4
5
6
7
8
9
10
Fantastic
Clear selection
Currently Experiencing
Blood Clots
Stress
Difficulty Sleeping
Irritability
Weight Gain
Weight Loss
Diarrhea
Constipation
Frequent Nausea
Skin Rashes
Hives
Psoriasis
Acne
Brain Fog
Fatigue
Low Energy
Joint Pain
Inflammation
Varicose Veins
Asthma
Sinus Issues
Food Sensitivities
Eczema
Autoimmune Flare
Heartburn or Indigestion
Reflux / GERD
Headaches
Migraines
Dizziness
Neuropathy
Difficulty Concentrating
Poor Memory
Depression
Anxiety
Irregular Periods
Heavy Periods
Painful Periods
Anemia
Post COVID symptoms
Other:
What is your main goal?
Your answer
When did you first notice the issue(s) that brought you here today?
Your answer
What do you think I should know about the issue(s)?
Your answer
In the past, what have you tried to address these challenges?
Your answer
Did that work for you?
Not even a little
It worked at first, then stopped working
It did work, but I am looking for better results
Other:
Clear selection
How are you feeling about your current challenges?
Hopeful
On a journey
Happy
Embarrassed
Frustrated
Overwhelmed
Confused
Conflicted
Dispapointed
Angry
Sad
Other:
How do you see yourself if you could overcome this challenge?
Elated
Relieved
Happy
Empowered
Proud
Any progress would be helpful
Other:
Allergies
Your answer
Food Sensitivities
Your answer
Other Sensitivities
Your answer
Are you pregnant?
Yes
No
Maybe
Trying
Clear selection
What state do you live in? (some services are not available in all states)
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Your answer
ONE LAST QUESTION...
I am interested in...
In person sessions (East Side, Providence, RI)
Remote Sessions
Both in person and remote sessions
All kinds of stress relief
Massage / Body Work
Reflexology
Energy Medicine
Health and Wellness Coaching
Ayurveda
Functional Medicine
The Autoimmune Protocol
Celiac Health
Herbal and Medicinal Plants
Counseling and non-religious spiritual guidance
Nutrition
Heat Therapy
Cold Therapy
Crystals
Aromatherapy
Thai Body Work
Acupuncture
Other:
We can't wait to meet you!
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Phone Number
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