The Wellness Collective

The Wellness Collective Discovery Assessment

Thank you for taking the time to complete this form. In our effort to support you as best as possible, The Wellness Collective providers will go over your answers to ensure your needs and goals are being met. If you have yet to become a client, our front desk staff will email you with our recommendations. You will then be able to set up the appointments you desire. If you are an established client, this form will be used to assess an updated baseline of your care. We are honored to walk with you as you heal, thrive, and be well.

Sources: The Institute of Functional Medicine, Nicole Cozean, PT, DPT, WCS, CSCS* and Jesse Cozean, MBA, Pfizer Inc. Copyright 1999, PRIME-MD is a trademark of Pfizer Inc. A2663B 10-04-2005

General Information

Please fill out the following information.

First Name *

Last Name *

Email *

Phone Number *

Birthday *

What state do you live in? *

What is your gender? *

Male

Female

Other

Prefer not to say

What is your biological sex? *

Male

Female

Prefer not to say

Please briefly describe what brings you into The Wellness Collective. What changes would you like to see? *