New Client Form

What do you want to accomplish with Worrell Wellness?

 

Some examples: to get stronger, to lose or gain weight, to feel better about myself, etc.

Are there any changes you've already made that you feel good about, or are getting you closer to your goals?

Please list any known food reactions, and indicate if its an allergy or sensitivity.  You can also share your food preferences.  What do you like?  What won't you eat?

 

For example:

Nuts - allergic

Gluten - sensitive

Prefer vegetarian meals, don't like mushrooms

Please indicate your bowel movement regularity and quality:

Do you frequently experience experience any of the following?

Please indicate you understand that:

  • Kacie Worrell performs education and coaching related to holistic nutrition, clean living and general wellness.

  • Kacie has a certification in Holistic Nutrition from American Fitness Professionals and Associates (AFPA) which will compliment her Associate's degree in Nursing and years of experience as an American Council for Exercise (A.C.E) group fitness instructor. 

  • Kacie is not a licensed or registered nutritionist/dietitian or medical professional and does not represent herself as one.

  • Any consultation or service is not intended as diagnosis, treatment, prescription or cure for any condition,mental or physical, real or imaginary, and is not a substitute for regular medical care.

  • You will consult your doctor before pursuing any course of action that involves dietary changes.

  • Worrell Wellness Team will make every effort to protect your information, and you can request us to erase all collected information at any time.

PO Box 1504, Stanwood, WA 98292

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