Relaxation – Functional Solutions & Wellness Services

What has attracted your interest in cannabis?(Required)

Have you ever tried cannabis in the past?(Required)

What is your current health condition(s)?(Required)

How long have you had this condition(s)?(Required)

What condition are you looking for cannabis to help you with?(Required)

Are you looking for daytime or evening/ night time use?(Required)

In terms of change, what have you already tried that hasn’t worked?(Required)

What medications, eye drops, skin creams do you currently take or use?(Required)

What supplements or herbs do you currently take, if any?(Required)

What state do you live in?(Required)

Name(Required)

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What has attracted your interest in working with a Functional Medicine (FM) provider?(Required)

Have you ever been seen by a FM provider before?(Required)

What is your current health condition(s)?(Required)

How long have you had this condition(s)??(Required)

In terms of change, what have you already tried that hasn’t worked?(Required)

What supplements or herbs do you take, if any?(Required)

What do you believe you must do in order to get the results you want?(Required)

What are your expectations of your provider?(Required)

What are your expectations of yourself?(Required)

What qualities do you currently possess that will help you achieve the results you want?(Required)

How will you define success for you from working with a FM provider?(Required)

Name(Required)

First Name Last Name

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Email(Required)

What has attracted your interest in receiving coaching services?(Required)

Have you ever been coached in the past?(Required)

Which area of your life are you looking to work on?(Required)

Please describe the your desires and dissatisfaction in the area of your life you’d most like to change?(Required)

How long have you been feeling this way?(Required)

In terms of change, what have you already tried that hasn’t worked?(Required)

What do you believe you must do in order to get the results you want?(Required)

What are your expectations of your Coach?(Required)

What are your expectations of yourself?(Required)

What qualities do you currently possess that will help you achieve the results you want?(Required)

What will define success for you from a coaching relationship or program?(Required)

Name(Required)

First Name Last Name

Phone

Email(Required)

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