WELLNESS WITH CHELA
Here to help you become your best self! xo
Name
First Name
Last Name
Email
example@example.com
Instagram Handle
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Are you interested in personal development to work towards the best version of yourself?
Yes! I need this in my life
Need more of it
I haven't really thought about it
Not interested
If you were to start on a personal development journey, what would you like to work on? Check all that apply.
Self-love and self acceptance
Fitness
Healthier habits
Spirituality/mindset
Relationship with money
Do you suffer from gut issues?
Yes, I am always uncomfortable
I think so, but I don't exactly know
My gut is great and I feel amazing
It needs some work
Are you currently experiencing any of the following? Check all that apply.
Bloating
Digestive issues
Low energy/fatigue
Autoimmune disorders
Anxiety
Brain fog
Fertility issues
Trouble sleeping
Other
Are you a mama?
Yes
No
Currently pregnant
Planning to be someday
Are you currently satisfied with your skin?
Yes, I love my skin
It's okay. Could be better
No, I struggle with confidence
No, I struggle with acne
I want to find a better skincare line
Are you experiencing any of these common skin issues? Check all that apply.
Acne
Oily skin
Dry skin
Signs of aging
Fine lines/wrinkles
Dark spots/Age spots/Sun spots
Dull skin/lacking glow
Eczema
Rosacea
None of the above
Other
Are you familiar with ingredients in wellness and beauty products and how these things can affect your overall health?
I'm familiar but don't really care
I'm somewhat familiar but could use some more info
I'm an avid label reader and all about low-tox life
I'm not familiar with how ingredients affect my overall health
Are you familiar with gut health and how this can affect your overall health, your skin, and your mental health?
I'm familiar but could use more info
Yes! I'm a gut health enthusiast
No
I want to help you thrive! What's the best way I can share resources with you to address some of these things that might be affecting your skin or overall health? Check all that apply.
Podcasts and book recommendations
Send me the deets on virtual workshops to learn more
Product recommendations for skin and gut health
All of the above
Can I add you to my "Wellness with Chela" group on Facebook where I share free resources, recipes, tips, product links, discount codes, and workouts for living your best life?
Yes, that sounds great
No, that's okay
Sorry I am not on Facebook
I'm already in it!
Would you be open to me recommending any products to help you with your skincare, gut health or non toxic needs?
Yes please! That would be so helpful
No thank you
You will message me about it
Are you open to hopping on a quick 15 min consultation call to discuss your survey?
Yes, I would love to!
No thank you
Sure, why not!
Submit
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