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Theresa Dale

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The Wellness Plan
This form will be sent to Dr. Dale's office, whereby they will recommend a
course of action to help you create your goals.
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Last Name*
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What are your Goals?

What Situations in Your Life Would You Like To Change?
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Are Your Ready To Change Your Life In Order To Achieve Your Goals?
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What are you Willing to Change in your life to Achieve your Goals?

Do You Believe You Have A Limitation(s) Preventing You From Achieving Your Goals?

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