Discovery Session - Sama Integrative Wellness

Book your Virtual Discovery Session with Veda Spidle now.

Duration: 30 minutes
Date:
Time:
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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 what you feel comfortable sharing.

What is your address? 

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

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Birthdate
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Emergency Contact Name
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Emergency Contact Relationship
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Emergency Contact Phone Number
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What is your occupation?

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

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What are your reasons for seeking this type of modality(-ies)?
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Have you been hospitalized in the past three years?
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Have you done yoga before?

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How healthy do you feel your diet is?

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How stressful do you feel your life is?

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

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How do you deal with stress?

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

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Do you generally feel well rested?

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

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Do you smoke?

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Are you currently pregnant?

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

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other:
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Please check any that apply to you:

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Other:
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If you have asthma, do you use an inhaler? 
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If you have diabetes, do you use insulin?
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Do you have a contagious disease?
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If you have had a surgery in the past five please explain more here:
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{"type":"textarea","name":"__generic22","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?"}


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Thank you for taking the time to fill out this form.
I look forward to connecting with you!