HELP ME UNDERSTAND YOUR GOALS
These quick questions will help me better understand what you’re struggling with and how I can support you with holistic tools. Let’s get started!
Your Wellness Vision
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
What are your top 1–3 health or wellness goals right now?(Example: Reduce pain, have more energy, improve sleep, balance hormones)
If you could wave a magic wand and fix one thing in your body or mind today, what would it be?
When it comes to making changes in your health or life, which best describes you?
I’m an “all-in” type — give me the full plan, all the tools, and let’s go!
I like to start slow — give me the essentials so I don’t get overwhelmed.
Somewhere in between — I want a clear plan, but I’ll take it one step at a time.
What’s Going On Right Now
Which of the following are you currently struggling with? (Select all that apply)
Low energy or fatigue
Pain or inflammation
Poor sleep or trouble staying asleep
Brain fog or memory issues
Stress or emotional overwhelm
Skin issues or slow healing
Hormonal imbalance (PMS, menopause, etc.)
Weight gain or slow metabolism
Digestive discomfort
Mood swings or emotional sensitivity
Numbness or tingling in limbs
Weakened immune system (frequent colds, illness)
headaches or migraines
Other
Follow-up (If 'Other' is selected): What else would you like to share?
How long have you been dealing with these issues?
Less than 1 month
1–3 months
3–6 months
Years (it’s been ongoing)
How would you describe your energy throughout the day?
Consistent and strong
Up and down – like a rollercoaster
I hit a wall mid-day
I feel drained all the time
Are there any therapies, treatments, or medications you’ve used in the past or are currently using that you feel have helped or haven’t helped?
Your Lifestyle + Current Approach
What have you tried already to support your body? (Select all that apply)
Supplements or vitamins
Chiropractor or acupuncture
Traditional medicine/medications
Essential oils
Energy healing or Reiki
Nothing yet – I’m just getting started
Other
Follow-up (If 'Other' is selected): What else would you like to share?
How open are you to trying a non-invasive, natural tool to support your body’s healing process?
Not At All
1
2
3
4
5
6
7
8
9
Very Open
10
1 is Not At All, 10 is Very Open
Final Notes
What would it mean for you to feel better in your body again?
💬 Thank you for sharing your responses!I’ll be reaching out to you shortly to discuss which holistic options may best support your needs based on what you shared. Let’s find what works best for you and get you feeling better—naturally. 💛 Aliesha
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