Wholistic Guidance Request | Michele Lynn Haszard

There are two forms listed below. The first being more spiritual guidance focused and the second

a broader coaching and guidance preference. Please review both before filling them out

and submitting. Adjustments in focus can be made at any point once we begin.

Wholistic Life Guidance I

First name

Last name

Email

Phone

Born gender

Male

Female

Birthday

Month

Day

Year

Address

Occupation

Are you currently taking any medications?

Yes

No

If yes, please indicate the medication name and the purpose below:

Do you have any health condition that you would like to share?

What is prompting you to seek wholistic guidance at this time?

Have you had spiritual guidance in the past? If so, what was that experience like for you?

If any, how do you describe your religious or spiritual affiliation, community, or belief system?:

If any, please share your spiritual or inner practices you currently engage in:

Describe your goals/achievements for our work together:

How did you find me, and/or who can I thank for referring you?:

Is there anything else you'd like to share with me at this time?: