wellness consult form

Hello and welcome! I'm so glad we get to meet. I'm here as a guide, to help you through the process of making lasting changes to your health and wellness.
Our session will hopefully be fun and constructive, and the questions below are intended to help me know you a little better.
[Any info you share is kept private, sent directly to my personal email, and not stored on our website.]

Name *
Name
Address *
Address
Phone Number
Phone Number
Please let me know what your exercise routine looks like. It's ok if your answer is "walking to the subway/4th floor walkup".
What is your skin like?
Please check all that apply.
If you menstruate:
Please let me know what your cycles are like, and check all the boxes that apply to you.
Please share any helpful details about your journey trying to conceive, such as how long you've been trying and what, if anything, you've used to help you, such as acupuncture, Fertility Awareness Method, supplements, etc.