Balanced Beings Community – Naturopath Consultation Application Form

Balanced Beings Community – Naturopath Consultation Application Form

Thank you for your interest in our Give Back Program! We are excited to offer free naturopath consultation sessions to those in need. Please complete the following form to be considered for this opportunity.
Full Name

First NameLast Name
Contact Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Health & Wellness background
Briefly describe any health concerns or challenges you are currently facing:
What are your main goals or areas you’d like support with through a naturopath consultation?
Have you ever worked with a naturopath or other health practitioners before?

YesNo
If yes, please provide details
Eligibility Criteria
Why do you believe you should be considered for a free consultation?
Please describe your current financial situation and why you would benefit from receiving a free consultation:
•Are you open to following recommended holistic health plans or lifestyle changes?

YesNo
Consent and Agreement
I consent to sharing my health information for the purpose of receiving a naturopath consultation under the Give Back Program.

YesNo
I understand that the free consultation is part of the Balanced Beings Community’s Give Back Program and is provided based on availability and eligibility.

YesNo
I agree to be contacted for follow-up if selected for the free consultation.

YesNo
Is there anything else you’d like to share that might help us understand your needs better?
Thank you for taking the time to fill out this application! Our team will carefully review all submissions, and if you are selected, we will reach out to you with further details regarding your free consultation.
Should be Empty: