Contact Us

Marie Avenue, Avalon, Pennsylvania 15202, United States

WELLNESS WORX INTAKE FORM

Ready to make positive changes in your life? Complete our intake form and let Wellness Worx help you move forward with confidence.

Name

Phone

How did you hear about us?

What do you want to accomplish?

What is important to you?

Why now? Why not stay the same?

What's the worst part of being overweight?

What's your biggest fear if you don't solve this now?

What's your biggest obstacle to fixing this?

How much longer are you willing to stay like this?

What else have you tried? Roughly how much have you spent on things that didn't work?

Why do you think those things didn't work for you?

Do you find yourself avoiding photos, swimsuits, shorts, or the pool?

Yes

Sometimes

What do you miss out on because of your weight? What's the worst part of that for you?

What is your current self-confidence level? (0 being not confident at all and 5 being very confident)