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Group Counseling Questionnaire

1.First Name(Required.)
2.Last Name(Required.)
3.Email(Required.)
4.Phone
5.How did you hear about Andrea and ReplenishPDX?
6.Time Zone

7.Please Check any ReplenishPDX programs you have purchased or participated in.
8.What is your most pressing health goal?
9.Do you have any known health or medical conditions. If yes, please explain.
10.Do you have any known food allergies, sensitivities or existing dietary parameters? If so, please list them here.
11.Please check the following items that are currently in your diet in any amount:
12.What percentage of your meals are currently home-cooked?
13.Please let me know anything else about you, additional goals or your health aspirations here.
14.Are you currently on the Replenish PDX mailing list?
15.Please select all of the days/times that work for you to attend group counseling so that we can find a good fit for you.

Thank you for taking the time to answer my questions so that I can make an group offer that best suits your needs.
After you complete the application, I'll add you to my
newsletter (recipes, tips & reviews), to support you
to elevate your health to the next level. It's also the best way to stay up-to-date on my new programs and offerings.
If you choose not to receive these you may unsubscribe at any time.
Warmly,
Andrea