The Mind Body Initiative Application

Please fill this out before your call

First Name

Last Name

Phone Number

Address

Occupation

Please list & describe your current challenges, symptoms or pain (physical/mental/emotional)

What percentage of the time do you experience these symptoms?

Please list all diagnoses

What would you like the most support with?

How "in control" do you feel over your current experince?

How would you describe your current physical health?

How would you describe your current mindset & emotional health?

How ready are you to start making changes in your life?

Have you ever worked with a coach or mentor to support you in your growth & healing?

How did you find/hear about the Mind|Body Initiative?

Why do you want to join the Mind|Body Initiative, and what do you hope to gain from the program?