Are You Well?

Please answer the questions below:

Do you experience anxiety/stress/tension?*

Do you experience depression/sadness?*

Attention or distraction issues?*

Memory retention or brain function issues?*

Anger/Jail/Detention?*

Suicidal or Homicidal Ideation?*

Do you suffer from insomnia or restlessness?*

Do you currently struggle with smoking, drinking or drug addiction?*

Do you isolate yourself from others?*

Do you feel you have strong support system?*

Do you have someone you can talk to?*

Do you ever experience feelings of worthlessness or hopelessness?*

Have you had a wellness check up from your dr. this year?*

Have you had annual labs drawn this year?*

Do you exercise regularly?*

Do you have fatigue/energy issues?*

Do you suffer from migraines or headaches?*

Do you have concerns about your nutrition?*

Would you like us to contact you regarding services?*

Location

Phone

Email

Preferred Contact Method

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