Well-being Protocol Questionnaire First Name, Last Name Your Email Phone Age Instagram/Facebook Handle Preferred Method of Contact Phone Text Email Social Please list any/all concerns about your wellness (physical, emotional, spiritual, relational) From the above list. Please tell me the Top 2 concerns you would like to address immediately What are your biggest obstacles when it comes to your wellness routine? Time Money Consistency Accountability Belief Other Current stress level (1—no stress, 5—moderate stress, 10—stress to max) How many times a week do you exercise? 1-2 times a week 3-5 times a week 5+ times a a week I don't How many hours of sleep do you get a night? 8+ hours 5-7 hours Less than 5 Any Dietary Restrictions I understand my well-being is an investment in myself; my well-being budget is? Less than $100 $150-$200 $250+ No price tag on my health Varies from month to month Would a 1:1 consultation, guidance and support be beneficial for you? Yes No My readiness to make changes or improvements to reach my optimal state of well-being. (1-very ready, 3-somewhat ready, 5-not sure yet) What tools or modalities do you currently use for your health? (Yoga, running, meditation, light therapy, acupuncture, etc) I want to know more about... unMasked Medicine Reading (Rachael's integrative modality to get to the root of your misalignment) Soul Contract Decoding CBD/Cannabis/Plant Wellness The Kintsugi Collective (healing community for women) Upcoming events and workshops Sign Me Up for The Kintsugi Letters Yes No Contact Us
