Empowered Wellness Audit

Excited to Get to Know YOU Better!

Completing this form allows us to empower you toward a more healthful life. By submitting this form you understand this is for information gathering purposes only. It does not establish a client-coach relationship.
Name

First NameLast Name
Email
example@example.com
Best Phone to Reach you Regarding Your Answers
Please enter a valid phone number.Format: (000) 000-0000.
What is your PRIMARY health goal?

Other
What stands in your way from achieving your goal?

Other
How high are your stress levels?

no worries-----------------------------------------------------------stressed out
How many hours are you sleeping at night
Do you have trouble staying hydrated?
Have you ever tried CBD for wellness?
Have you ever tried Functional Mushrooms for wellness?
Are you taking any medications for:

Other
Indicate the TOP health item you would like to seek support on and the average number of YEARS you have struggled with the issue.
ex. poor sleep, 25 years,,, or pain left leg, 10 years
Please use this space to share expand on any answers regarding your health, CBD or mushroom experience, or any PET issues (YES WE SERVE PETS AS WELL).
Your Age (or the age of the person of inquiry)
How did you connect with us? USE DROPDOWN
If Other or Referred, by who?
How ready are you to up level your health and wellness?
Should be Empty:

Excited to Get to Know YOU Better!