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Home
About Me
Services
Shop Online
Suppliments
Books
Blog
Contact Us
FAQs
Centerl Park West La, New York
+0 123 456 7890
info@example.com
LATEST POST
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16 March 2023
Endometriosis Resources
16 March 2023
Initial Consulting
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Full Name
*
Email Address
*
Phone Number
*
Age
*
City & State / Country
*
Occupation
Marital Status
*
Single
Married
Divorced
Widowed
Prefer not to say
Do you have children?
Yes
No
What brings you to Roots Harmony Wellness?
*
What are your top 3 health concerns right now?
*
Endometriosis
Fibroids
Chronic pain
Hormonal imbalance
Fatigue
Burnout
Weight challenges
Inflammation
Digestive issues
Stress/anxiety
Sleep issues
Irregular cycles
Fertility concerns
Brain fog
Emotional overwhelm
Other
How long have you been experiencing these symptoms?
*
--- Select Choice ---
Less than 6 months
6 months–1 year
1–3 years
3–5 years
More than 5 years
Have you been formally diagnosed with any condition(s)?
*
rate of How
Which symptoms do you currently experience?
*
Pelvic pain
Painful periods
Heavy bleeding
Bloating
Chronic inflammation
Joint pain
Fatigue
Headaches
Mood swings
Anxiety/stress
Sleep disturbances
Digestive discomfort
Low energy
Hormonal symptoms
Weight fluctuations
Brain fog
Low libido
Other
On a scale of 1–10, how would you rate your daily stress level?
Selected Value:
0
On average, how many hours of sleep do you get per night?
*
--- Select Choice ---
Less than 5
5–6
6–7
7–8
8+
How would you describe your current energy levels?
*
Very low
Low
Moderate
Good
Excellent
How would you describe your current eating habits?
*
Do you currently follow any specific nutrition or wellness lifestyle?
*
Anti-inflammatory
Gluten-free
Dairy-free
Plant-based
High-protein
Intermittent fasting
Whole-food focused
None
Other
Do you fast?
Yes
No
If yes (Above)
OMAD (one meal a day)
TMAD ( two meals a day)
If yes: how long if do you fast?
12 hrs
16 hrs
20 hrs
24 hrs
36 hrs
48hrs
More
How often do you exercise or move your body?
Rarely
1–2x/week
3–4x/week
5+ times/week
What type of movement do you typically do?
Walking
Strength training
Yoga/stretching
Running
Pilates
Functional fitness
Weights lifting
None
Other
Do you currently take supplements?
Yes
No
If yes, please list them below.
How would you describe your emotional wellness right now?
Have you experienced significant stress, grief, burnout, or emotional overwhelm in recent years?
Yes
No
Prefer not to say
What areas of your life feel most out of balance right now?
Health
Career/work
Relationships
Energy
Emotional well-being
Sleep
Time management
Nutrition
Movement
Purpose/direction
Other
What are your primary wellness goals?
What would “feeling better” look like for you?
What type of support are you most interested in?
1:1 consultation
12-week Reset
6-month coaching
Wellness education
Lifestyle guidance
Functional wellness support
Supplement guidance
Not sure yet
Are you ready to make lifestyle changes to support your health goals?
Yes
Somewhat
Not yet
Disclaimer
*
I understand that this consultation is educational and wellness-focused and is not a substitute for medical care.
Roots Harmony Wellness provides wellness education and coaching and does not diagnose, treat, cure, or replace medical care. Please consult your licensed healthcare provider regarding medical concerns or medical emergencies.
Is there anything else you would like us to know before your consultation?
How did you hear about Roots Harmony Wellness?
Instagram
LinkedIn
Referral
Podcast
Amazon/book
Website
Friend/family
Other
Submit
RHW annual VIP retreat waiting list (Inquiry)
Ready to begin your healing journey? Join the RHW waitlist to be the first to know when a space opens for 1:1 programs, group cohorts, or retreats. ✨ For women ready to move from managing symptoms to truly understanding their body. ✨ For those seeking clarity, structure, and support that honors their full story.
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First Name
*
Last Name
*
Note Name of
Phone Number
*
Email
*
Number of People Interested
*
Special Note
Submit
Corporate Wellness Program
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Organization Name
*
Point of Contact
*
Email
*
Phone Number + Extension
*
Your Role
*
Number of Employees
*
--- Select Choice ---
1–10
11–50
101–250
250+
Wellness Solutions Interested In
*
Leadership skills coaching
Health and stress assessments
Employee wellness workshops/retreats
Executive leadership coaching
Burnout prevention & resilience training
Custom wellness strategy & policy integration
Ongoing check-ins & well-being reporting
success outcomes Preferred
What are your biggest wellness concerns for your team?
*
What outcomes would you like to see from a corporate wellness program/what does success look like for your organization?
*
Preferred Start Time
*
Immediately
In the next 1–3 months
In 3–6 months
Not sure
Additional Comments
*
Location and Timezone
*
Submit
