Apply To Work With Three Sixty Wellness

Thank you for your interest in working with The Three Sixty Wellness Team. We are equally as excited to help you reach your goals as you are hoping to achieve them!

Fill out this form below and then find a time to book a video call on the next page!

First Name *

Last Name *

Email *

Phone *

Instagram Handle *

How did you hear about us?! *

Instagram

TikTok

Facebook

Friend/Word of Mouth

Other (please list below, or mention your friend!)

Who were you referred by? We love to send thank you's!

Click all that apply to you: *

Leakage

Urgency to urinate

Frequently Urinating

Low back pain/SI joint pain

Hip pain

Tailbone pain

Abdominal pain

Painful intercourse

Pelvic floor tension

Rib flaring

Constipation

Pelvic pressure/heaviness (prolapse)

Urinary retention

Frequent UTIs

Lack of sexual arousal

Pregnancy pains

Painful urination/bowel movement

Other not listed

How long have you been struggling with these issues? *

<6 months

1 year

1-2 years

2+ years

On a scale of 1-10, how important is it to you to fix the problems listed above? *

0-2

2-4

6-8

8-10

Which one best describes you currently? *

No children

I am currently pregnant

I am < 1 year postpartum

I am > 1 years postpartum

I am perimenopausal

What are the biggest hurdles you’ve been trying to overcome on your own? *

Tell me about your goals! What is your ultimate goal 4-6 months from now? What do you want to be doing? How do you want to feel? *

Do you and your significant other make financial decisions together? Do they know you are booking this call and are supportive of a decision that you will make? If we align together we can get you onboarded during this call. *

Are you ready and willing to invest time and financial resources for 1-on-1 support in solving your problem? (FYI: We DO accept HSA/FSA payments, but we are not in network with insurance.)

YES I am ready and willing to invest both time and financial resources into my health and I have my partners support if this program aligns with me.

MAYBE I actually am very ready to solve these concerns, but may need to come up with a financial payment plan to make this work for me.

NO, I am not ready to invest financially or my time into this even if that means I have to wait and figure it out on my own.

Anything else you'd like to add before booking?