Getting to Know You

This short survey allows us to get a snapshot of your needs and desires for holistic health coaching services. 

Upon completion of the survey, you'll be able to schedule a complimentary Strategy Session to discuss our services and help you determine how our health coaching can best fit your needs. 

Are you ready to become the CEO of your health and a healer in your own home?

It all starts here!


Here's to your wellness -
amy Miller photoAmy O Miller
Wellness Advocate & Coach,
3LifeEssentials
832.509.5093 || amy@3LifeEssentials.com || 
3LifeEssentials.com || Share wellness. Share Jesus. 

Personal Information


Friend or healthcare professional referral
Webinar
Website
Telegram
Other
Support with a specific health condition. Please specify below.
Lose some weight, increase energy, or just a general sense of "I am not feeling as good as I could."
I need support with my child's condition (ie. Autism, ADD, ADHD, Asthma, Skin Issues, Behavior, Sleep, Nutrition). Please specify below.
I was referred by another practitioner (Please let us know who in the space below).

Not much, just getting started
I've tried a few things, but I am overwhelmed by the information out there
I've been to a few health practitioners trying to figure this out, and understanding or relief is still a mystery.
Other

Soda
Diet Soda
Refined Sugar
Alcohol
Fast Food
Snack Food (chips, pretzels, etc)
Dessert/candy (chocolate, cookies, candies, Twinkies, etc.)
Gluten (wheat, rye, barley)
Dairy (milk, cheese, yogurt)
Coffee
None of the above

Less than 25%
25-50%
50-70%
70-100%