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 form, you'll be able to schedule a complimentary Strategy Session to

help you see is possible for you and to guide you toward the next step. 


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 have been chronically ill for a long time and no one has been able to help me feel better.
I would like some healthier ways to manage emotions and stress.
I would like support with fertility.


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
Fermented foods
Filtered water
None of the above