Your Contact Information

First Name *

Last Name *

Email Address *

Mobile Phone

How did you find us?

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Referrer Name

Mailing Address

City

Postal Code/Zip

Country

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Province/State

Program Length & Dates

Program Length (7, 14 or 21 Days)

Please Select One

Session Date

Select Your Depth of Healing

Who will be looking after the payment?

Please select one

Program Questionnaire:

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?

Are you aware the Fresh Start is not a Rehab/Treatment Center?

Yes

Why Fresh Start, instead of rehabs?

Do you currently take any meds?

Yes

MEDICATION DETAILS

MEDS DETAILS: Please provide: Name, dosage, what it is taken for, how long you've 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 Down?

Yes

Select your level

Recent Surgeries

Yes

Surgery details

Do you currently smoke?

Yes

Do you smoke or vape?

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.

Would you like to also quit smoking, while at Fresh Start?

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:

Fresh Start meals are dairy, gluten, meats, fish and other seafood, sugar and eggs free. Would you need to order meal customization for nuts fruits, veggies, nuts, seeds, herbs or greens, we'll review and let you know if we can customize that ingredient and any additional charges involved. Do you have any food texture issues or a food disorder?

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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