Intake form

Name *

Email address *

What are your primary goals for improving your well-being?

Please select at least one option.

Physical health

Mental health

Emotional well-being

Work-life balance

Social connections

Personal development

How often do you engage in self-care activities?

What types of activities do you currently practice to enhance your well-being?

Please select at least one option.

Exercise

Meditation

Reading

Hobbies

Socializing

Healthy eating

What challenges do you face in maintaining your well-being?

How did you hear about us?

Additional questions or comments

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