Discovery Sessions - Sama Integrative Wellness

Choose

In-Person Discovery Session

Introductory in-person meeting to explore your needs. view more...

Virtual Discovery Session

Introductory virtual meeting to explore your needs. view more...

hide

Book your In-Person Discovery Session with Veda Spidle now.

Duration:	30 minutes
Date:	Showing times in
Time:
	Continue

Name: *
Email: *
Cell Phone: *

Welcome to Sama Integrative Wellness!

A holistic approach to therapy is a transformative practice that integrates the body, mind, and spirit. If I know more about you, it will facilitate our process together as we co-create your experience.

In addition to the required fields, please fill out only what you feel comfortable sharing.

What is your address?

Fill this in if only if you intend to have any sessions at your location.

{"type":"textarea","name":"clientaddress","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please type in NA if this is not applicable to you.","height":120,"placeholder":"Address Here"}

Birthdate or Age

{"type":"text","name":"birthdate","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please enter your birthdate or age.","placeholder":""}

Emergency Contact Name

{"type":"text","name":"__generic","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please enter an emergency contact.","placeholder":""}

Emergency Contact Relationship

{"type":"text","name":"__generic2","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please enter an emergency contact.","placeholder":""}

Emergency Contact Phone Number

{"type":"text","name":"__generic3","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please enter a phone number for your emergency contact.","placeholder":""}

How did you find out about Sama Integrative Wellness?

{"type":"textarea","name":"referral","width":100,"value":"","size":"Normal","validation":"","validationMessage":"If you prefer to not share, please type in NA.","height":80,"placeholder":""}

What is your occupation?

{"type":"textarea","name":"clientoccupation","width":100,"value":"","size":"Normal","validation":"","validationMessage":"If you prefer to not share, please type in NA.","height":80,"placeholder":"Occupation"}

Would you like to join the Sama Integrative Wellness email list?

Yes No{"type":"radio","name":"joinemaillist","width":100,"value":"","size":"Normal","validation":"C1","validationMessage":"Please choose \"yes\" or \"no\".","options":"Yes\nNo"}

What are your reasons for seeking this type of modality(-ies)?

{"type":"textarea","name":"whySama","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please share something, even if the answer is: I'm not sure. ","height":80,"placeholder":"Please share why you want to try out what Sama Integrative Wellness has to offer."}

Have you been hospitalized in the past three years?

Yes No{"type":"radio","name":"joinemaillist2","width":100,"value":"","size":"Normal","validation":"C1","validationMessage":"Please choose \"yes\" or \"no\".","options":"Yes\nNo"}

{"type":"textarea","name":"__generic4","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please share something, even if the answer is: I'm not sure. ","height":80,"placeholder":"If so, what was/were the reason/reasons?"}

Have you done yoga before?

Yes No{"type":"radio","name":"joinemaillist3","width":100,"value":"","size":"Normal","validation":"C1","validationMessage":"Please choose \"yes\" or \"no\".","options":"Yes\nNo"}

{"type":"textarea","name":"__generic5","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please share something, even if the answer is: I'm not sure. ","height":80,"placeholder":"If you have done yoga before, what styles? Please list them here."}

How healthy do you feel your diet is?

Very Good Good Fair Not So Good Very Bad Prefer Not to Answer{"type":"radio","name":"diet","width":100,"value":"","size":"Normal","validation":"C1","validationMessage":"Please choose one answer.","options":"Very Good\nGood\nFair\nNot So Good\nVery Bad\nPrefer Not to Answer"}

How stressful do you feel your life is?

No Stress Mild Stress Moderate Stress Much Stress Extreme Stress Prefer Not to Answer{"type":"radio","name":"stresslevel","width":100,"value":"","size":"Normal","validation":"C1","validationMessage":"Please choose one answer.","options":"No Stress\nMild Stress\nModerate Stress\nMuch Stress\nExtreme Stress\nPrefer Not to Answer"}

What is (are) the main causes of stress in your life?

{"type":"textarea","name":"stresscause","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please share something, even if the answer is: I'm not sure. ","height":80,"placeholder":"What stresses you out?"}

How do you deal with stress?

{"type":"textarea","name":"destressby","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please share something, even if the answer is: I'm not sure. ","height":80,"placeholder":"What destresses you?"}

How many hours of sleep do you typically get a night?

{"type":"text","name":"hoursofsleep","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please share the amount of sleep you get a night in a numerical value. ","placeholder":"Please enter a numerical value."}

Do you generally feel well rested?

Yes No{"type":"radio","name":"wellrested","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please choose \"yes\" or \"no\".","options":"Yes\nNo"}

How many cups of water do you typically drink in a day?

{"type":"text","name":"water","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please share the amount of cups of water you drink a day in a numerical value. ","placeholder":"Please enter a numerical value."}

Do you smoke?

Yes No{"type":"radio","name":"smoke","width":100,"value":"","size":"Normal","validation":"C1","validationMessage":"Please choose \"yes\" or \"no\".","options":"Yes\nNo"}

Are you currently pregnant?

Yes No Not Applicable{"type":"radio","name":"__generic13","width":100,"value":"","size":"Normal","validation":"C1","validationMessage":"Please choose one of the answers.","options":"Yes\nNo\nNot Applicable"}

Are you currently consulting a/an (please check all that apply)?:

Acupuncturist Āyurveda Practitioner Chiropractor Massage Therapist Naturopath Nutritionist Physician Physical Therapist Psychologist Reiki/Energy Balancing Practitioner{"type":"checkbox","name":"AdditionalCare","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please check at least one item.","options":"Acupuncturist\nĀyurveda Practitioner\nChiropractor\nMassage Therapist\nNaturopath\nNutritionist\nPhysician\nPhysical Therapist\nPsychologist\nReiki/Energy Balancing Practitioner"}

other:

{"type":"textarea","name":"AdditionalCare_comment","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please share the amount of cups of water you drink a day in a numerical value. ","height":80,"placeholder":"Please list any other professionals you are currently seeing."}

Please check any that apply to you:

Addiction to Drugs/Alcohol Anxiety Arthritis Asthma (Please review additional question below.) Back Pain Bipolar Disorder Bruise Easily Cancer Chronic Pain Communicable Disease (Including, but not limited to shingles, hepatitis, HIV.) Depression Diabetes (Please review additional question below.) Ear Issues Epilepsy Eye Issues/Glaucoma Fibromyalgia Headaches Hearing Loss Heart Trouble High Blood Pressure Hypoglycemia Insomnia Intestinal Disorders Joint Swelling Low Blood Pressure Migraines Osteoporosis Pace Maker Implant Seizures Sinus Condition Sleep Difficulties Stroke Surgery in the Past Five Years (Please explain more below.) Thyroid Issues Wear Contact Lenses Whiplash{"type":"checkbox","name":"difficulties","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please check at least one item.","options":"Addiction to Drugs/Alcohol\nAnxiety\nArthritis\nAsthma (Please review additional question below.)\nBack Pain\nBipolar Disorder\nBruise Easily\nCancer\nChronic Pain\nCommunicable Disease (Including, but not limited to shingles, hepatitis, HIV.)\nDepression\nDiabetes (Please review additional question below.)\nEar Issues\nEpilepsy\nEye Issues/Glaucoma\nFibromyalgia\nHeadaches\nHearing Loss\nHeart Trouble\nHigh Blood Pressure\nHypoglycemia\nInsomnia\nIntestinal Disorders\nJoint Swelling\nLow Blood Pressure\nMigraines\nOsteoporosis\nPace Maker Implant\nSeizures\nSinus Condition\nSleep Difficulties\nStroke\nSurgery in the Past Five Years (Please explain more below.)\nThyroid Issues\nWear Contact Lenses\nWhiplash"}

Other:

{"type":"textarea","name":"difficulties_comment","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please share the amount of cups of water you drink a day in a numerical value. ","height":80,"placeholder":"Please list any other difficulties here that you are experiencing physically."}

If you have asthma, do you use an inhaler?

Yes No Not Applicable{"type":"radio","name":"__generic18","width":100,"value":"","size":"Normal","validation":"C1","validationMessage":"Please choose one of the answers","options":"Yes\nNo\nNot Applicable"}

If you have diabetes, do you use insulin?

Yes No Not Applicable{"type":"radio","name":"__generic19","width":100,"value":"","size":"Normal","validation":"C1","validationMessage":"Please choose one of the answers.","options":"Yes\nNo\nNot Applicable"}

If you have had a surgery in the past five please explain more here:

{"type":"textarea","name":"__generic20","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please share the amount of cups of water you drink a day in a numerical value. ","height":80,"placeholder":"Please explain more about your recent surgery/surgeries."}

What does optimal health mean to you?

{"type":"textarea","name":"optimalhealth","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please share something, even if the answer is: I'm not sure. ","height":80,"placeholder":""}

What gives you a sense of meaning and purpose in life?

{"type":"textarea","name":"purpose","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please share something, even if the answer is: I'm not sure. ","height":80,"placeholder":""}

What are your creative outlets?
{"type":"textarea","name":"creativeoutlets","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please share something, even if the answer is: I'm not sure. ","height":80,"placeholder":""}

What aspects of your life give you the most joy and pleasure?

{"type":"textarea","name":"joy","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please share something, even if the answer is: I'm not sure. ","height":80,"placeholder":""}

Is there any additional information you would like to share?

{"type":"textarea","name":"__generic6","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please share something, even if the answer is: I'm not sure. ","height":80,"placeholder":""}

Thank you for taking the time to fill out this form.

I look forward to connecting with you!

Book your Virtual Discovery Session with Veda Spidle now.

Duration:	30 minutes
Date:	Showing times in
Time:
	Continue

Name: *
Email: *
Cell Phone: *