Home & Health Reset Survey

We'd love to get to know you and support your personalized reset! If you already submitted the quick intake, you can skip the repeated fields or just complete what you'd like!

Step 1: Basic Info

Full Name

Phone

Yes, I consent to receive occasional text updates related to my Home & Health Reset journey with Vitality Wellness.

Address

Zip Code

Email

Yes, sign me up for monthly Vitality Wellness updates!

Preferred Contact Method

What Upgrades (if any) are you dreaming about for your home?

Select any topics you'd like to explore- wellness, energy upgrades or both!

Step 2: Your Home & Lifestyle

Which option best describes your living situation?

How many people live in your home?

What type of home do you live in?

Approximately what year was your home built?

Do you know the age of your roof?

What's your average monthly electric bill?

Upload Recent Electric Bill

Already have solar?

Select all that apply if you currently have solar.

I already have solar, but I'm interested in other home upgrades

I'd like to add a battery or expand my system

I have solar and love it - I'd like to refer a friend or neighbor

How Do You Heat & Cool Your Home?

File upload

Have you looked into Mass Save home upgrades like insulation, HVAC, solar, or rebates within the last two years?

Single choice

Yes

No

Current Home Environmental Concerns

Upload photo(s) of home or areas of concern (optional)

Step 3: Your Wellness Journey

Which options best describe where you're at now on your path to wellness?

Currently ill or healing from an illness

Suspected mold, Lyme, or parasite exposure

I'm just getting started, new to wellness

Rebuilding after burnout, heartbreak or stress

Curious about holistic health

Looking for a reset in my environment (home, lifestyle, routine)

Emotionally or spiritually ready to change

Preparing for a big life season (wedding, pregnancy, move, career change)

On a healing path, but not sure what I need yet

Have you ever done a structured detox?

Yes, recently

Yes, but it's been a while

No, I'm new to it

Step 4: Almost Done!

How Did You Hear About Us?

Please select one

Would you like to refer a friend or family member for a home & health reset consult or free home energy upgrade quote?

Would you like to enter our D&G SMEG or Vertical Garden raffle?

Yes!

Maybe later

No thanks

Rate Your Vitality Wellness Experience

Add any notes you'd like to share before your consultation.

Terms & Consent

I have read and agree to the Vitality Wellness Terms, Conditions & Privacy Policy and consent to being contacted regarding my inquiry.

VITALITY WELLNESS

HOME & HEALTH RESET