The Spirit. Soul. Body. Experience

The Spirit. Soul. Body. Experience

Intentional Wellness
"Come away with Me by yourselves to a quiet place, get some rest. Mark 6:31

Please take a moment to answer honestly. There are no right or wrong answers, only clarity for the care you need in this season.
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Gender*

MaleFemale
Phone Number*
Email*
example@example.com
Marital Status*

SingleMarriedDivorcedWidowed
Occupation*
SECTION 1: Your Current Season
1. Which best describes your life right now?

Full, but manageableBusy and often overwhelmedConstantly pouring out with little time to refillExhausted, disconnected, or on the edge of burnout
2. How often do you feel truly rested? Spirit, Soul, & Body

RegularlyOccasionallyRarelyAlmost never
3. When was the last time you took intentional time for your own care (not errands or obligations)

Within the last month1-3 months ago3-6 months agoI honestly can't remember
SECTION 2: Body & Nervous System Check-in
Which symptoms resonate with you?

Chronic fatigue or low energyTension, pain, or headachesTrouble sleeping or staying asleepAnxiety, irritability, or emotional heavinessFeeling disconnected from your bodyFrequent illness or slow recovery
5. When you do rest, does your body actually relax?

Yes, easilySometimesRarelyNo, I stay tense even when I stop
SECTION 3: Soul & Spiritual Care
6. How would you describe your current spiritual state?

Grounded and nourishedSomewhat dry or inconsistentSpiritually tired or depletedPouring into others but not being poured into
7. Do you feel safe receiving prayer and care without needing to lead or perform?

YesSomewhatNot reallyI deeply long for that
SECTION 4: Support & Commitment
8. What kind of support do you need most right now?

A single sacred pauseConsistent monthly careDeep, structured restorationWhole-life healing and guidance
9. Are you open to committing to a rhythm of care if it supports real healing?

Yes, absolutelyYes, with some flexibilityI'm open but unsureI'm not ready for a commitment
10. In your own words, what do you hope will feel different after receiving care?
AGREEMENT:

I understand that all information entered in this form will be considered strictly confidential. The responses gathered from this form will only be used as a basis for recommending the Care Path for my season.

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

You are not weak for needing rest. You are wise for responding to the invitation.
We will prayerfully review your responses and recommend the Care Path that best supports your healing in this season.
Should be Empty:

The Spirit. Soul. Body. Experience

"Come away with Me by yourselves to a quiet place, get some rest. Mark 6:31

SECTION 1: Your Current Season

SECTION 2: Body & Nervous System Check-in

SECTION 3: Soul & Spiritual Care

SECTION 4: Support & Commitment

We will prayerfully review your responses and recommend the Care Path that best supports your healing in this season.