The Spirit. Soul. Body. Experience

The Spirit. Soul. Body. Experience

Intentional Wellness
Name*

First NameLast Name
Age*
Date of Birth*

MonthDayYear
Date
Gender*

MaleFemale
Phone Number*
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Marital Status*

SingleMarriedDivorcedWidowed
Occupation*
Are you currently taking any medications?*

YesNo
If yes, then please indicate the medication name and the purpose below:
Do you have any health conditions that you would like to share?*

YesNo
If yes, then please share them below:
What are your personal/professional goals?*
What are your spiritual/emotional goals?*
What is something you can celebrate about yourself? (What are you proud of?)*
What changes would you like to make in your life right now?*
What is your self-care routine?*
Do you receive Therapeutic Massage? If yes, how often?*
Do you regularly detox? If yes, what type?*
Describe your relationship with Christ?*
Services Desired:*

Individual CoachingGroup CoachingTherapeutic MassageDetox Services
How did you find out about our services?*

Social MediaYouTube VideoSearch EngineFamily/Friend
AGREEMENT/REMINDERS:

I understand that all information I entered in this form will be considered strictly confidential. The data gathered from this form will only be used as a basis for the type of services the client will be offered.

I understand that in order to be successful, I need to be honest and authentic. I will not be ashamed to ask for help.

If I am working with more than one professional, I will make all professionals aware of my participation in other programs/services.
Signature*

Powered by Jotform SignClear
Should be Empty: