Discovery Questionnaire

Ready to be made well?

You've already taken the first step by exploring Viriditas Health.

The next step isn't booking an appointment.

It's sharing your story.

Every person's health journey is unique, and I'd love the opportunity to learn more about yours before we meet.

Your story deserves to be heard, and helps me understand:

• where you've been

• where you are today

• what you're hoping for

• and whether Viriditas Health is the right fit for your journey.

Every submission is personally reviewed by me.

If it seems we're a good fit, I'll personally invite you to schedule a complimentary Discovery Call.

Discovery Questionnaire

Wholistic Wellness & Integrative Health Consults

Every wellness journey begins with a story, and I'd love to hear yours...

Before we schedule a Discovery Call, I invite you to share more about you, where you're at now, and what you're hoping to achieve. Your responses help me prepare for a meaningful conversation and determine whether Viriditas Health is the right fit for your needs.

Please complete the following form and I will be in touch to schedule a call with you shortly.

Thank you for taking the time to start the conversation.

Full Name *

Date of birth *

Gender: *

Address

Street Address *

City *

State *

Country *

Postal Code *

Phone *

Email *

What do you do for work? *

How did you hear about me? *

If you could eliminate 3 symptoms, what would they be? *

Have you had any of the following exposures, currently or in the past? *Please select all that apply

Anything else I should know?

Please enter any applicable info

How badly are these problems affecting your life? *

DOES NOTPROFOUND AFFECT

How committed are you to getting better? *

NOT VERYVERY COMMITTED

Be honest!

Stacy can not diagnose, treat, or prescribe. The relationship between Stacy and her clients is one of educator and client. It is fully the client's choice whether or not to take advantage of the information Stacy presents.

Signing below indicates your agreement and acceptance of the above disclaimer. *

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