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TRANSFORM HEALTHCARE THROUGH CONNECTION
Join the Dignity in Healing Community
Registration Form
First Name
Last Name
What are you most wanting help with?
Anxiety depression
Current life events
Chronic health condition(s)
Relationship(s)
Current trauma
Past trauma
Health behavior change (diet, habits, exercise)
Grief
Feeling overwhelmed
Making a life decision
Parenting/Caregiving,
Confidence/Self-esteem
Substance abuse/addiction
I’m not sure but I know I need support
Other
How long have you been wanting to make changes in this area?
I just started thinking about this
I’ve been thinking about this for some time
I have already started to make some changes
I have made some changes and want to maintain them
What type of provider are you looking for?
Health/Wellness Coach
Medical Provider
Mental Health Therapist
Psychiatric Medication Provider
Not sure
What is most important to you in a health/wellness provider?
Experience
Listening skills
Accountability for me
Guidance and support
Fresh ideas
Collaborative care with other providers
Exercises and practices I can do at home
Not sure
Other
What best describes your financial situation?
I have insurance and only want services my insurance covers
I do not have insurance and can pay for services out-of-pocket
I have insurance and can also pay for services not covered by insurance
I do not have insurance and cannot pay for services out-of-pocket
If you have health insurance, which one(s)?
What times can you meet with your health/wellness provider?
Mornings
Afternoons
Evenings
Weekends
Flexible
Do you prefer virtual or in-person meetings?
Virtual
In-person
Either virtual or In-person
Did anyone refer you to us?
My primary care provider
Another healthcare provider
Family member or friend
Internet search
Health Insurance company
Place of employment
Other
What else would you like us to know?
Email
Phone number
We want to get back to you as soon as possible. Please indicate the ways in which we can follow up?
Phone
Text
Email
Any of the above
Register now
