Your Contact Information

First Name *

Last Name *

Email Address *

Mobile Phone

How did you find us?

Referrer Name

Mailing Address

Address

Street Address

City

Province/State

Country

Please Select One

Postal Code/Zip

Pogram Length & Dates

Program Length

Session Date

Number of people attending

Please Select one

Name of other participants

Are you a repeat guest?

Please select one

Date of your last visit?

Please let us know if you have any additional questions as you decide whether Fresh start is what you are looking for?

Program Package Interest

Select Focus

Select Your Depth of Healing

What health concerns are you currently facing, if you have any?

What do you realistically hope to gain from attending a wellness program at Fresh Start within 7-14-21 Days?

What attracted you to Fresh Start?

Are you comfortable to be in a group environment?

Yes

Do you currently take any meds?

Yes

MEDS DETAILS: Please provide: Name, dosage, what it is taken for, how long you have been on it and the meds effectiveness. Prozac, 10 mg (twice a day), for Depression/Anxiety, on it for 10 yrs. It works for me but makes me lethargic. NOTE: spelling of the medication is most important, in case we need to research it.

List your medication

Any supplementation you are on?

Yes

List your supplementation

Do You Need Assistance To Go Up And Downn?

Yes

Select your level

Surgeries in the last 6 month?

Yes

Surgery details

Do you smoke?

Yes

Do you smoke or vape?

Please select one

If you have decided to quit and need help, please ask Program Consultant about a dedicated Quit Smoking Program. This program is not designed for that.

Do you use recreational drugs?

Yes

What kind and how often?

Do you consume Alcohol?

Yes

What kind and how often?

Are you Pregnant or might be pregnant?

Yes

Organic Vegan Meals

Do You Have Any Food Texture Issues Or A Food Disorder?

Yes

Food texture issues or a food disorder details

Allergies/Food Sensitivities

Yes

Substances that provoke reaction

Allergies - Severe Reaction

Yes

Do You Require An EpiPen® Injection, In Case Of An Allergic Reaction?

Please select one

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