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The Wellness Plan

By Theresa Dale
Friday, November 9th, 2012

This form will be sent to Dr. Dale’s office, whereby they will recommend a course of action to help you create your goals.




First Name
Last Name
Age
Phone
E-Mail

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    • How did you hear about us?

 

    • Next visit
    • day

 

    • What are your Goals?

 

    • What situations would you like to change
    • 1.
    • 2.
    • 3.

 

    • Are Your Ready To Change Your Life In Order To Achieve Your Goals?
    • YesNo

 

    • 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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