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Root to Heal Connection Form


Thank you for taking the time to complete this form.


This is not a commitment or a formal medical intake. It is simply a starting point to help me better understand your goals, experiences and what type of support may be most appropriate for you.


Please answer in whatever level of detail feels comfortable. I will reach out to you very soon!

Preferred Method of Contact
Text
Email
Phone Call
No preference
What type of support are you interested in? Select any that apply:
Are you interested in:
Virtual Options
In Person Options
Either Virtual or In Person
What goals or areas of support are you seeking? Select any that apply:
Have you practiced yoga or mnd-body practices before?
Yes, regularly
Yes, occasionally
Very little
Never
Unsure

The information provided on this website is for educational and informational purposes only and is not intended as medical advice, diagnosis or treatment. Participation in any Root to Heal program does not establish a patient-provider relationship and does not replace care from your primary healthcare provider. All health decisions should be made in consultation with your licensed medical professional. Individual results vary, and no guarantees are made regarding outcomes. Root to Heal services focus on education, strategy and collaborative support. Clients are responsible for decisions regarding their medical care.

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