The Gaia Roots Foundation - Wellness Request Form

Wellness Support Request Form

Please Fill the form below and we will get back to you soon. If your filling out the form on behalf of someone please fill all their details below.
Are you filling out this form for

YourselfOn behalf of an adultOn behalf of a child
Name

First NameLast Name
Date of Birth

DayMonthYear
Gender
Phone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Have you accessed any Gaia Roots or partner wellness services before?
Are you currently experiencing financial hardship?
Which of the following best describes your current situation?

Receiving government benefits (e.g., unemployment, disability, social assistance)StudentSingle parent / primary caregiverLow-income employmentCurrently unemployedOther
Have you had any wellness therapies/healing before? If yes please list below.
Are you currently experiencing any physical, emotional, or mental health challenges?
How would you describe your current wellbeing?

I’m coping but feeling low or anxiousI’m feeling burnt out or emotionally drainedI’ve experienced trauma or loss recentlyI’m in recovery (physical, mental, or emotional)
Please tell us a little about why you are reaching out for wellness support at this time:
Which wellness treatments/ Therapies are you interested in?

ReikiContrast therapy - Sauna/ cold therapyHimalayan salt TherapyCounsellingAcupuncatureSound therapyNaturopathyApothecaryCompression therapyBreathwork/ Meditation
Anything you would like to add -
Should be Empty:

Wellness Support Request Form