Phone *

First Name

Preferred first name

How do you prefer to receive communications

I prefer to be called
I am best with text
Email is my preferred method of communication
Text for brief messages, email otherwise
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Wellness Readiness & Compatibility Assessment

I am all about helping you improve your quality of life. Please rate the following:

What is your level of commitment to improving your life and health?

Rate "1" as least applicable to "10" most applicable to you.

To what degree of improvement needs to be made for you to be healthy and happy?

Rate your satisfaction level with your life overall:

What specific changes are you most eager to see in your health and wellness?

Are you familiar with naturopathic or holistic health practices

Please select all that apply

Yes, I have seen a variety
I have some experience
I have some exposure
This is my first real attempt
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Are you taking any medications or supplements that we should be aware of *

Select all the apply:

Yes, currently but recently added
Yes, I have taken supplements long-term
I am not consistent taking my supplements
I take prescribed medicine
N/A
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Let's Get Real

Please check all that apply:

Emotional Health:

I feel tired or low-energy

I experience anger or frustration often

I feel depressed or anxious

I struggle with negative self-talk

Physical Health

I experience daily pain or inflammation

I am overweight or underweight

I don’t sleep well or wake up feeling rejuvenatedI don’t sleep well or wake up feeling rejuvenated

Lifestyle

I often put my priorities on the backburner

I feel overwhelmed or short on time

I distract myself with social media, TV, or gaming

I sometimes overdo it, leading to stress or burnout

There is an imbalance of life and work

I don't feel like there is enough time

I often feel overwhelmed or depleted

Relationships & Life Satisfaction

There could be some improvement in my relationships

I tend to be slow to open up

Friends are surface level, or fair-weather friends

I have 1-2 close friends

If not for my efforts, friendships wouldn't be maintained

I would like the opportunity to cultivate quality relationships

I feel some guilt when I do things to care for my needs

How important to you would it be to wake up most days feeling excited and ready to begin your day?

What other practitioners or providers have you consulted?

What led you to complete this assessment? (Select all that apply):

A friend or family member recommended it

I found it through your website or social media

Via exploring a program or service

I feel an urgent need for health and wellness support

I’m ready to make changes with professional guidance

I’m curious about how naturopathy could help me

Other

Holistic care is not a substitute for medical diagnosis, especially for insurance purposes; do you agree? *

Yes
No
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Any Additional Comments, Questions Or Special Requests?

Signature *

Clear

Upon submission, you will be redirected to complete a Nutrition Assessment Survey