* 1. Do you have any chronic or repeating injuries?

* 2. Have you been diagnosed with:

* 3. Are any of these true for you?

  Yes No
Are you considering surgery or recovering from surgery?
Do you work with health practitioners but feel that something is missing / you have an incomplete picture of your health?
Do you feel tired and/or low energy?
Do you wish you could feel less emotional and/or stressed? Do you have problems with anger and other emotions?
Would you like more mental clarity, feel more centered, make better decisions?
Have you experienced trauma in your life? (accidents, loss of loved ones, abuse)
Do you have difficulty with significant relationships in your life? Would you like to experience more harmony and/or deepen your relationships?
Would you like to experience more joy in your life?
Are you interested in learning more about your own energy and how to better manage it / interact with others?
Are you interested in a deeper spiritual connection or connect with your life purpose?

* 4. Please list your top 3 goals for better overall wellness and quality of life

* 5. May we contact you to discuss your situation further?

* 6. If yes, please enter your name and contact information below

* 7. Thank you for completing this survey, we will contact you shortly to discuss your unique situation and needs.