APOTHECARY
SPIRITUAL WELLNESS SERVICES
1:1 COACHING
INTEGRATIVE HERBAL SERVICES
INTUITIVE YOGA & GUIDED MEDITATION
CRYSTAL ENERGY & REIKI HEALING SERVICES
HOLISTIC DOULA CARE
EVENTS | CLASSES
THE DESIGNATED HEALER PODCAST
THE DESIGNATED HEALER BLOG
SPIRITUAL WELLNESS SERVICES QUESTIONNAIRE
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Name:
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First
Last
Email:
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Phone Number:
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Occupation:
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Select One
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Unemployed
Part-time
Full-time
Self-employed
I identify as...
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Male
Female
Prefer Not To Say
Race
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African- American/ Black
Latinx
Indigenous People
Hispanic
Asian
Caucasian
Other
Choose One
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Less than 13
13-18
19-25
26-35
36-50
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Which service are you interested in?
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Crystal Energy Healing
Reiki Healing
Guided Meditation
Intuitive Yoga Instruction
Integrative Herbalism
ARE YOU FAMILIAR WITH ANY OF THE SERVICES WE OFFER?
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Yes
No
If yes, please give more detail
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Do you or have you ever experienced any of the following:
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Depression
Anxiety
Emotional Overwhelm
Burn out
Lack of motivation
Loss of a loved one or close friend recently
Mental Illness
Eating Disorder
Trauma
Spiritual Crisis
Existential Crisis
Suicidal Thoughts
I'd rather not say
Have you been evaluated by a mental health professional?
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Yes
No
IF SO, PLEASE ELABORATE ON YOUR DIAGNOSIS (AS IT APPLIES TO YOUR SESSION):
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What area of your life are you looking to improve?
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Self
Career
Romantic relationship
Family
Financial
Emotional
Psychological
Intimacy/ Sexual
Spiritual
Physical
What are some issues you are currently dealing with that lead you to seek out sprituial wellness services?
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What motivates you to make changes in your life?
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SUBMIT
APOTHECARY
SPIRITUAL WELLNESS SERVICES
1:1 COACHING
INTEGRATIVE HERBAL SERVICES
INTUITIVE YOGA & GUIDED MEDITATION
CRYSTAL ENERGY & REIKI HEALING SERVICES
HOLISTIC DOULA CARE
EVENTS | CLASSES
THE DESIGNATED HEALER PODCAST
THE DESIGNATED HEALER BLOG