What's next for your health, wellness, and personal evolution?

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So you're ready for a shift! I'm glad you're taking your health and well-being seriously. I'd like to get a sense of what's going on in your life and what you'd like to see change, which this questionnaire is designed to provide.

Note: If you're a Willamette Valley local and you'd like to receive acupuncture and herbs with me, you need not fill out this form. Just call the office at (541) 757-4868 and we will set you up with an initial series of visits.

Email *

Full name *

Phone number *

What major shift or breakthrough in your health, happiness, or personal evolution would you like to experience over the next year? *

What's prompting you to want to make this change now? *

Where are you at right now? Please check all that apply: *

I feel stressed, anxious, and/or overwhelmed frequently

I'm tired (unless I use caffeine)

I feel like there's no time for ME in my life

I frequently feel down, unmotivated, and/or depressed

I'm not experiencing much joy

I feel disconnected from my body and my intuition

I don't nourish myself particularly well

I eat well, but don't digest well

I'm not sleeping well or enough

I'm carrying more weight than I'm comfortable with

I feel irritable, short-tempered more than I'd like

I'm really hard on myself

I feel guilty for taking care of myself / setting boundaries

I feel like I'm struggling to keep up with all I have going on

I'm consuming more sugar, alcohol, junk food than I'd like to alter my mood

I have a chronic health condition that I'd like to keep at bay

Other:

Required

How have you tried to solve this problem already? What's been helpful and what hasn't? *

Among the things I help people with are establishing healthy habits. Which of the following are you interested in? *

I want more restful sleep

I want to eat healthy, nutrient-rich food in the right quantities for my body

I want to digest that healthy food better

I want to do a better job honoring my body's needs

I want a solid practice of meditation, mindfulness

I want to feel less stressed, anxious, overwhelmed

I want to experience more energy, motivation, and joy

I want to feel less irritable, impatient, angry, or frustrated

I want to move through life from a place of ease

I want my inner dialogue to be kinder

I want to break up with perfectionism or people-pleasing

I want to create more time for my creative pursuits, people in my life, and for myself

I want to establish the habits that will help me age optimally

I want to feel like there's time for me in my life

I want a bigger self-care toolbox so I can make more medicinal choices

Other:

Required

What could be keeping you from feeling how you want to feel? Again, check all that apply: *

My current habits don't support my goals

I'm trying to do it all myself and haven't invested in support

I've been prioritizing other things over my health and wellness

My peers don't have the same goals / there's little social support

I'm not sure -- i just feel stuck

Required

How ready and willing are you to prioritize your health and personal growth at this time? *

barely

totally

Which offering are you most interested in? *

Level Up Your Life (6 month membership)

One-on-one coaching

Acupuncture / Chinese herbs at my clinic in Corvallis, Oregon

Other:

Required

What is it about me or my message or approach most resonates with you? And how did you hear about my work? *

Is there anything else you'd like me to know?

Send me a copy of my responses.

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