Consultation Intake form - CW
Thank you for your interest in our private consultation service!
We ask that you please complete with as much detail as possible and submit at least 1 day before your 20 minute consultation.

Please click this link to select your appointment date and time: https://thecountryway.simplybook.me#book/service/1

For payment information, please follow the instructions on the bottom of this intake form.
Thank you!
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Email *
First Name *
Last Name *
Email *
Phone Number *
Current Age *
What are you hoping to get out of this consultation? *Please be as specific as possible* *
Please rate your: *
Poor
Average
Great
Excellent
Overall Health
Quality of Sleep
Energy Levels
Digestion
Stress Management
Digestive concerns - please check all that apply: *
Required
How often do you exercise on a weekly basis? (elevated heart rate with physical activity for 20 minutes or more) *
What types of physical activity and exercise do you participate in?
What are your main health goals? (Select all that apply) *
Required
How would you rate the daily stress in your job? *
How would you rate the daily stress in your home life? *
Please list all natural supplements you are currently taking: *
Do you have any known existing health conditions? *
What do you feel has been the biggest barrier lately in trying to achieve your health goals?
Is there any specific health concern you want to discuss during your consultation?
Payment Information
Thank you for your interest in our private 20 minute consultation service, we ask that complete payments of $28.25 ($25.00 + HST)  be submitted the day prior to your appointment. You can make a payment by:

- Giving us a call with a credit card over the phone at 705-949-1898
- Etransfer sent to carol.trotter@thecountryway.ca
- Pay in store in person Mon-Fri 10am - 5pm or Sat 10am-4pm

Thank you, we look forward to working with you 1:1 and helping guide you on your health journey!
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