Application for 1:1 Health Coaching at The Wellness Table LLC

Please complete the application below and schedule a Discovery Call!

Pets in the home?

Yes

No

If "yes" to pets, what kind of pets?

Dog

Cat

Dog and Cat

Other

Are you currently under the care of a physician? (This is not asking whether you have a primary care provider, it's asking if you have a health issue currently being managed and/or monitored by your physician.)

Yes

No

Are you currently taking any prescriptions?

Yes

No

Were you referred by anyone or by a past or current client

Yes

No

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