Wufoo
One on One Client Application
Welcome to Peace on My Plate Wellness!
By completing this form, you help to clarify your intentions so I can best support you in achieving your dreams and desires - intentions are like the map, without clear direction we can feel lost and unsure even where to start, thus their importance to gain momentum!
Share as much or as little as you choose, and use as much space as you need. Anything you write here is held in complete confidence, and when you click 'Submit', I will receive it securely via email. I look forward to working with you!
If you haven't already done so please click here to schedule your 30 minute session with me where we will clarify your intentions and speak further about your next steps. https://my.timedriver.com/TZZWM
Any other questions please feel free to email me: eliza@peaceonmyplate.com
With Love & Support,
Eliza
Name
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First
Last
Phone Number
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Email
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How did you hear about me?
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Goals & Intentions
What are your top 3 reasons for coming to
me for support?
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Improved Self Care
Low Self Esteem/Confidence
Improved Relationships
Stress
Spirituality
Low Energy
Depression/Anxiety
Guilt/Feelings of Unworthiness
Reproductive/Hormonal issues
Other
If you had to narrow it down, what would you say is your #1 biggest struggle in your life right now?
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What physical, emotional, spiritual or lifestyle patterns would you like to see improve? From 0 to 10 how committed are you to solving this issue once and for all (0 - don't care and 10-need it solved yesterday!)
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I want you to get the most out of our time together. During our session, what is most important to you that we cover?
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Thank You! I look forward to our session!
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