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POLAT WELLNESS STUDIO
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Free Trial
6 Week Application Form
Full Name
*
Phone
*
Location / Time Zone
*
Email
*
What is the main pattern you want support with?
*
Emotional eating
Stress eating
Nighttime eating
Chaotic routines
Stress + nervous system dysregulation
Inconsistent habits / low structure
Feeling “off” / overwhelmed
What currently feels the most dysregulated in your life?
*
What have you tried before, and what hasn’t worked?
*
What do you want to feel or experience after 6 weeks?
*
Are you able to commit to a weekly 60 minute session?
*
Yes
No
Are you open to gentle structure, somatic tools, and micro behavioral shifts?
*
Yes
No
Do you currently have any active crisis, eating disorder treatment, or therapy requiring immediate care?
*
Yes
No
If yes This program may not be the best fit right now.
Preferred days for weekly sessions:
*
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
How soon would you ideally like to begin?
*
As soon as possible
Within 1–2 weeks
Within 1 month
This program is $850. Are you prepared to invest in this 6-week journey?
*
Yes, I’m ready
I may need installment options
Not sure, want to discuss
Submit
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