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Nutrition
1-on-1 Wellness Coaching
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Nutrition
1-on-1 Wellness Coaching
Yoga
Consulting
Courses
Contact
$
0.00
Cart
Home
About
Journal
Shop
Nutrition
1-on-1 Wellness Coaching
Yoga
Consulting
Courses
Contact
X
1-on-1 Wellness Coaching
1-ON-1 WELLNESS COACHING FORM
Name
*
First
Last
Age
*
Location
*
City & State (Region)
Email
*
Profession OR Career Field
*
Household status
Single - living with yourself
Single - living with family etc.
Living with parter (with or without family etc.)
Living separate from partner (with family etc.)
Living separate from partner (with yourself only)
Health Status: Do you have any active injuries, diagnoses, or regular prescription medication?
*
Yes
No
What result(s) would you like to accomplish together in your first 3 months to feel successful & on track with your overall wellness goals?
*
Please rank your level of motivation to develop & commit to a personal wellness regimen on a scale 1 ("unconcerned & unbothered") to 10 ("ready & prepared")
*
Please rank your level of interest is alternative and/or natural therapies on a scale of 1 ("not at all interested") to 10 ("I'm so glad you asked")
*
Have you received any natural or alternative healing treatments in the past?
*
Yes
No
If yes, please name the treatments (ie: massage, acupuncture, yoga therapy, healing touch, etc.)
*
Type N/A if none
EcoEmpress (Virtual) Nutrition & Wellness Coaching does NOT accept insurance. Are you ok with paying out-of-pocket?
*
Yes
No
Are you interested in including Yin Yoga, Meditation, or Yoga Nidra sessions in your coaching?
*
X