Research Study

Be apart of a our research study and win a Free Chakra Mug! Winner will be announced June 16, 2014.

* Indicates required field

How would you rate your overall health? *

Poor Fair Great

Do you have access to wellness classes in your community? *

Yes No Some

Would you like to see more wellness intervention in your community? *

Yes No

How much would you pay per yoga class, nutrition class and meditation class? Feel free to give a reason. *

Where do you go to heal yourself from illnesses? *

Where do you go to sustain your health? *

Gender *

Female Male

What is your age? *

Less than 13 13-18 19-25 26-35 36-50 Over 50 Prefer not to say

What is your household income? *

Less than $10,000 $10,001 - $25,000 $25,001 - $40,000 $40,001 - $70,000 $70,001 - $100,000 Greater than $100,000 Prefer not to say

In what state do you desire to live the in? *

To be entered in the drawing for a FREE CHAKRA MUG please type in your email address below: *

Submit

Thank you for supporting www.returntoyourself.org and contributing to community wellness.

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