To help us personalise your wellness experience, please take a moment to complete this quick assessment.

Last Name

1. Contact Information

First Name

Phone *

Email *

Address

Street Address

City

State

Country

Preferred Method of Contact

Email

SMS

Phone Call

2. About You

Occupation:

Do you regularly prepare your own meals?

Yes

No

Sometimes

3. Wellness Focus Areas

What are your current wellness goals? (Tick all that apply) *

Improve my nutrition & eating habits

Increase my energy levels

Lose weight

Manage or reverse a health condition (e.g., diabetes, hypertension)

Improve mental wellbeing & stress management

Improve family health habits

Detox my kitchen (non-toxic cookware, healthier cooking)

Learn more about plant-based/oil-free cooking

Be part of a supportive wellness community

4. Your Current Challenges

Which of these are you currently struggling with? (Tick all that apply) *

5. Your Kitchen Setup

6. Health Status (Optional but helpful)

7. Lifestyle Snapshot

How regularly do you exercise? *

Daily

2–3 times/week

Occasionally

Not at all

8. Support Preferences

Would you like to book a FREE 1:1 wellness consultation with one of our Coaches? *

Yes, please!

Not right now

9. Anything Else We Should Know?

Please Enter Here

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