All About You

Congratulations on taking the first step to enhancing your health and wellness! Please tell us a little about yourself and we’ll contact you to schedule your free 30 minute introductory session.

[th-contact-form subject=”Lets Get Started Submission Form” to=”kristen@mixwellness.com” button_text=”Here We Go!!” captcha=”1″]
[th-contact-field label=”Name” type=”name” required=”true” /]
[th-contact-field label=”Email” type=”email” required=”true” reply=”true” /]
[th-contact-field label=”Phone” type=”phone” required=”true” /]

 

Health & Wellness Goals

(select all that apply)

Overall *

[th-contact-field label=”Improve personal well-being (health and happiness)” type=”checkbox” /]
[th-contact-field label=”Improve family well-being” type=”checkbox” /]
[th-contact-field label=”Improve energy” type=”checkbox” /]
[th-contact-field label=”Improve productivity” type=”checkbox” /]
[th-contact-field label=”Improve finances” type=”checkbox” /]

Mental & Emotional *

[th-contact-field label=”Improve work/life balance” type=”checkbox” /]
[th-contact-field label=”Improve sleep” type=”checkbox” /]
[th-contact-field label=”Manage stress better or reduce stress” type=”checkbox” /]
[th-contact-field label=”Improve job satisfaction” type=”checkbox” /]
[th-contact-field label=”Improve personal relationships” type=”checkbox” /]
[th-contact-field label=”Manage drug or alcohol issues” type=”checkbox” /]
[th-contact-field label=”Improve life satisfaction” type=”checkbox” /]

Physical/Health *

[th-contact-field label=”Increase physical activity” type=”checkbox” /]
[th-contact-field label=”Manage or prevent injury” type=”checkbox” /]
[th-contact-field label=”Lose weight” type=”checkbox” /]
[th-contact-field label=”Manage or maintain current weight” type=”checkbox” /]
[th-contact-field label=”Improve eating habits” type=”checkbox” /]
[th-contact-field label=”Improve health risks or medical conditions” type=”checkbox” /]
[th-contact-field label=”Reduce need for medications” type=”checkbox” /]
[th-contact-field label=”Reduce or quit smoking” type=”checkbox” /]

Preferred Service (optional)

[th-contact-field label=”Preferred Service” type=”select” options=”Undecided,Program A,Program B,Program C,Introductory Session,Vision & Goal Setting,Subsequent Sessions” /]

[/th-contact-form]