VIRTUAL HOLISTIC & WELLNESS THERAPY SESSIONS

Wellness and Holistic Therapy Intake Form

Congratulations on taking the first step toward a transformative and balanced life! My name is Shera Hill, also known as The Meditation Chic, and I am thrilled to welcome you to our TMC Holistic & Wellness Therapy Virtual Sessions.To help us better understand your needs and aspirations, please take a moment to fill out the form below. This will allow us to tailor your wellness and holistic therapy experience to support your unique journey.
Your Wellness & Holistic Coach (Shera B Hill)

Life Coach, Motivational Speaker, Holistic Wellness Practitioner, Breath-work Master Instructor, Founder of Brown Boujie Balanced Retreats
Personal Information
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Gender

MaleFemale
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact Number*
Email
example@example.com
Emergency Contact Name
Emergency Contact Phone Number

Area CodePhone Number

Health and Wellness Background
What are your primary reasons for seeking wellness and holistic therapy?

Stress managementPhysical health improvementMental health supportEmotional healingOther: ___________
Please list any past or current medical conditions:
Are you currently taking any medications? If yes, please list them:
Real results for real people. Whether your goal is to

* Lose weight

* Gain weight

* Shape up

* Increase energy

Then this is for you. See some of our many results from all over the world below

Lifestyle and Habits
How would you describe your current lifestyle? (e.g., little to no movement, moderate activity, active, etc.)
Do you exercise regularly? If yes, what type of exercise and how often?
How are your energy levels during the day?*

TerribleLowAverageGoodAmazing
Do you practice any form of meditation or mindfulness? If yes, please describe:*
How would you rate your current stress level on a scale of 1-10?
Do you use any alternative therapies?*

AcupunctureChiropractic careHerbal supplements

Past Experiences
Have you previously engaged in any wellness or holistic therapies? If yes, please describe your experiences:
What did you find beneficial in your past experiences?
Were there any challenges or aspects you did not find helpful?

Present Situation
What are your current wellness and health goals?
What are the main challenges you are currently facing in achieving these goals?
What is your why? Is there an event you are working towards? Or do you want to clean up your lifestyle? Be specific!*
How serious are you about your health goals?*

Not verySort ofSeriousVery serious

Alternative Care
Are you open to trying alternative therapies? If yes, which ones are you interested in?

Wellness and Holistic Therapy Intake Form