Consults - Eclectic Energies Yoga

Name *

First

Last

Email *

Date of Birth (mm/dd/yy) *

Gender

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How did you hear about us?

What would you like to change or improve about your lifestyle? *

List any additional things that you would like to change or improve. *

What do you expect to gain from your experience here at Eclectic Energies? *

Please list any mental health conditions, previous traumas, or harmful habits that you may have: *

Have you ever gone to therapy? If so, please share the type and the outcome. *

Emergency Contact (Name & Phone #) *

Is there anything else you'd like to share?