JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
POWELLNESS - Reset, Reframe & Relax Form
Please read and e-sign below.
Once completed we will arrange a call so you can ask any additional questions and confirm your space.
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Email
*
Your email
Full Name
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Phone number
*
Your answer
Confirm Email Address
*
Your answer
Why do you feel you need a break?
*
Your answer
Do you find it hard to relax and if yes why?
*
Your answer
What would you be hoping for us to provide?
*
Your answer
Please tick what applies to you most
*
Self-employed (Solo)
Run a business (Have employees)
Work for a company
Other:
Required
Are you currently under medical supervision?
*
No
Yes
If you answered 'Yes' Please explain
Your answer
Are you currently taking any medication?
*
No
Yes
If you answered 'Yes' Please explain
Your answer
Please tick any conditions that apply to you
Stress or Anxiety
Fear or Phobia
Anger or Resentment
Weight Issues
Money Issues
Trust Issues
Menopause
Anxiety about Aging
Empty Nest
Divorce or Breakup
Marriage or Relationship Problems
Traumatic Memories
Workaholic
Sadness
Low Self-Esteem
Chronic Pain
Grief
Lack of Purpose
Confidence
Public Speaking
Feeling Unworthy
Feeling Overwhelmed
Other:
Please explain any you listed
Your answer
Relationship Status?
Your answer
Children?
Your answer
Dietry requirements?
*
Your answer
Do you smoke, use alcohol or other substances?
*
Your answer
How often do you exercise?
Your answer
Please tick what applies to you most
*
People Person
Reserved
Outgoing
Task Lead
Other:
Required
What's the best holiday experience you've had and why?
*
Your answer
Confidentiality
All parties acknowledge and confirm that any oral or written information exchanged among them with respect to this form constitutes confidential information.
The Parties shall maintain the confidentiality of all such information.
E Signature
*
Your answer
Date
*
MM
/
DD
/
YYYY
A copy of your responses will be emailed to the address you provided.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
Privacy
Terms
This form was created inside of Move And Prep.
Report Abuse
Forms
