Individual Consultative Inquiry Form

4411 Suwanee Dam Rd. Suite 545

Suwanee, GA 30024

678-765-0445

www.mindgymtwi.com

admin@mindgymtwi.com

Wellness is not merely the absence of illness or distress. Wellness is striving for a positive physical, mental/emotional, financial, professional, lifestyle, and social wellbeing. It is a lifelong process of making decisions that support a more balanced life to maximize your potential. There are always opportunities for enhancing your wellness, and it starts with self-reflection and setting goals.

Please fill out this assessment to determine the areas that may need greater attention.
Date

MonthDayYear
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Name
Email
example@example.com
Phone (optional)
Format: (000) 000-0000.
Preferred way to be contacted
How did you find out about us/our services
Please describe your main concern or the area(s) of growth you would like to improve (e.g., stress management, fitness, nutrition)
What motivates you to make changes right now?
Do you prefer 1:1 coaching or group support?
When would you like your consultation to start?
Best days/times for sessions
Do you prefer in-person or virtual consultations?
4411 Suwanee Dam Rd. Suite 545

Suwanee, GA 30024

678-765-0445

www.mindgymtwi.com

admin@mindgymtwi.com

I understand that all information I entered in this form will be considered strictly confidential. The data gathered from this form will only be used as a basis for the type of coaching the client will need.

Disclaimer for wellness use:

This form is for wellness coaching purposes only. We do not provide medical diagnosis or treatment, and the information you share here is not considered medical records under HIPAA. If you are seeking medical advice, diagnosis, or treatment, please consult a licensed healthcare provider.

Thank you for allowing us to support your wellness journey! A team member will contact you to answer any questions and schedule your consultation with one of our licensed instructors.
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