Intake form

Name *

Email address *

What are your primary health goals?

Please select at least one option.

Weight Loss

Muscle Gain

Increased Energy

Improved Mental Clarity

Stress Reduction

Better Sleep

Enhanced Overall Wellness

Do you have any current health conditions?

Please select at least one option.

Diabetes

Hypertension

Heart Disease

Asthma

Digestive Disorders

Thyroid Issues

None

What is your current level of physical activity?

How would you rate your current stress level?

What dietary preferences do you follow?

Please select at least one option.

Vegetarian

Vegan

Paleo

Keto

Mediterranean

None

Have you previously worked with a wellness coach?

What mind-body techniques are you familiar with?

Please select at least one option.

Hypnotherapy

Reiki

Access Bars

Meditation

Yoga

None

What are your expectations from working with a holistic coach?

Which service or services are you interested in?

Please select at least one option.

The Wellness Code: Transform Your Body & Metabolism

🔮 Rapid Transformational Therapy (RTT) – Reprogram Your Mind for Success

🔮 Tarot Reading – Gain Insight & Guidance for Your Life Path

⚡ Access Bars – Clear Energy Blocks & Unlock Mental Clarity

🌿 Reiki Healing – Restore Balance & Inner Peace

Additional questions or comments

OMHEALING