Getting to Know You

This short survey allows us to get a snapshot of your needs and desires for holistic wellness 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 services 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%