LIT Lotus - Wellness Goals Assessment

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Email *

Please provide your first and last name. *

Let's begin by assessing your current mind and body state. Check all that apply. *

I'm tired/have low energy frequently

I often feel overwhelmed

I am frequently stressed-out

I feel disconnected from my body

I am lacking work/life balance

I feel burned out

I regularly engage in negative self-talk

I am unhappy with my weight

I suffer from anxiety/depression

I regularly do not sleep well

I suffer from inflammation in the body (arthritis, auto-immune disorders, etc)

I am impatient/frustrated frequently

I have poor digestion

Other:

Required

Living Inspiration Tribe is about building habits for a better life. What are your desires or goals? *

I want to feel reconnected to my body

I want to lose excess weight

I want to have consistent energy

I want less stress in my life

I want to have regular digestion

I want to find balance in my life

I want to eat a healthier diet

I want to take better care of my mind and body

Other:

Required

Describe in more detail what health or lifestyle breakthroughs you want to experience. Take a minute - please provide some context or detail. *

What is keeping you from experiencing your best self? *

My peers don't have the same goals or habits

I need help staying accountable

I don't know where to start to make the changes I would like

I haven't been coached by someone who has reached the goals I want

I try to go it alone and find it difficult to stick to these changes

My family doesn't support a lifestyle change

I haven't invested in the right support

I give up easily when I don't see the progress I think I should

Required

Are you ready to make changes to have the life you want? *

Yes

Unsure

Are you ready and able to commit time & financial resources to up-level your habits and identity? *

Yes

Unsure

How did you hear about Melinda VanKirk Wellness?

Web search

Social Media

Friends or colleagues

Workshop or Event

Yoga Studio

Other:

Any other details you would like to share?

If you are being honest with yourself, what might prevent you from showing up for this call? *

Phone Number *

Almost done . . .

After you click "Submit" I will reach out to schedule a complimentary Self-Discovery call with you to find out more about your wellness goals. It's so much fun, and you are going to love it. I will be in touch soon!

Namaste -
Melinda

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

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