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Hāʻehuola Wellness Interest Form

Join the Hāʻehuola Wellness Program

Mahalo for your interest in the Hāʻehuola Wellness Program. Please share a bit about yourself so we can guide you to the best next step.

First Name *

Email *

Phone *

How did you hear about us? *

Healthcare provider

Insurance plan

Employer / organization

Friend or family

Social media

Event or class

Other

Are you currently connected with any of the following? (click all that apply) *

AlohaCare

United Health Care

Kaiser Permanente

HMSA

Waimānalo Health Center

Other

What is your primary interest in the program *

Improving overall health

Managing a health condition

Learning about plant-based nutrition

Building healthier habits

Community and support

Other

Are you currently managing or seeking support for any of the following? *

Prediabetes or diabetes

High blood pressure

High cholesterol

Heart health concerns

Weight-related health concerns

Other

Prefer not to say

Are you applying as part of a group or organization? *

Yes

No

Not sure

Preferred Start Time *

As soon as possible

Within the next 1–3 months

Just exploring for now

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