Getting to know you!

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We are so excited to get to know you and partner with you on your journey toward optimal health. Please take just a moment to get to know us and allow us to begin getting to know you. Talk to you soon!

Email *

Name (First and Last) *

Phone Number *

Are you a current Wellness+ member? *

Yes

Not yet but plan to join soon.

Not a member and have no immediate plans to join.

Other:

Wellness Consultant Shared Information Acknowledgment

This information will be shared with our Wellness Director and will then be used to select a Wellness Consultant that best suits your needs. If you are not comfortable with this, please do not fill out this form. Thanks!

Gender *

Female

Male

Prefer not to say

Other:

Do any of the following apply to you? *

El español es mi idioma preferido. (Spanish is my preferred language)

Seeking gender specific services.

None of the above apply to me.

Referred by a community practitioner (please include who in the following question)

Please describe why you want to meet with a Wellness Consultant. Please be as thorough as you wish. *

Are you currently under the care of any medical professional (dietician, doctor, psychologist, nutritionist)?

Yes

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If yes above, please describe.

Please list any current and past medical diagnoses that you are comfortable discussing.

A copy of your responses will be emailed to the address you provided.

Submit

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