Get to Know You

Getting to Know You

This short survey allows us to get a snapshot of your needs and desires for holistic wellness services.

Upon completion of the form, you'll be able to schedule a complimentary Strategy Session to

help you see is possible for you and to guide you toward the next step.

Are you ready to become the CEO of your health and a healer in your own home?

It all starts here!

Here's to your wellness -

Amy O Miller

Wellness Advocate & Coach,

3LifeEssentials

832.509.5093 || amy@3LifeEssentials.com ||

3LifeEssentials.com || Share wellness. Share Jesus.

Personal Information

First Name

Last Name

Mobile Number

We'd love to know how you found us or who referred you. (Please first choose a category and then provide us the specific resource below.)

Please identify specifically how you found us. (ie. name of the podcast or the name of the person/health care provider who referred you.) If you have a Referral Code please enter it here

What are your main goals for considering additional support?

Support with a specific health condition. Please specify below.Lose some weight, increase energy, or just a general sense of "I am not feeling as good as I could."I need support with my child's condition (ie. Autism, ADD, ADHD, Asthma, Skin Issues, Behavior, Sleep, Nutrition). Please specify below.I have been chronically ill for a long time and no one has been able to help me feel better.I would like some healthier ways to manage emotions and stress.I would like support with fertility.

Please specify the condition or diagnosis that you are seeking support for, if applicable:

Please list any medications, herbs, essential oils, and supplements you are currently taking.

Please include any additional notes here

On average, how many ounces of water do you drink daily?

We are committed to working with individuals who are dedicated to their health and ready to receive support on their individualized journey to health and healing. Is there anything else we need to know about you?

832.509.5093

info@3lifeessentials.com

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