Intake Form

Thank you for signing up to work with me. I am so excited to make this a beautiful transformation so that you have more energy, more time and more ease to fully enjoy your life. I am dedicated to supporting and empowering you on your journey through motherhood and self development. Please take a few moments to fill out this intake form to help me understand your needs better and provide you with the best support possible.

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Birth date

YYYY

Height & Weight

Ancestry/Ethnicity

Family & Living Situation:

Occupation

Allergies

Please list food, medicine and environmental

Health care providers you are seeing?

Medical conditions/ procedures during the last 7 years

What is your regular exercise routine and recreational activity? How often?

What are your top 3 biggest stressors that are on-repeat often?

If there was a magic button, what would be erased, resolved or fixed for you today?

What health goals would you like to address? Please provide an onset date.

How have you dealt with these concerns thus far?

List any supplements or medications you are taking and for what purpose for each

Use sheet back for more space

Please list any addictive behaviors

(Past and present use and abuse of alcohol, drugs, food, tobacco, birth control pills, caffeine, food, codependency, workaholism…)

Please describe the condition and tendency of the following

Skin, Hair, Nails

Tell me how your presenting concerns impact you & your life & your family & partner?

Do you have any injuries (past or present)? If so, where are they located and how do they affect you?

Have you done allergy, blood, pulse or saliva testing? Elimination diet? Journaling?

What is a typical day like for you now from wake to sleep? Include all you do during a day along with the times and how you feel. Please include a typical day's meals with all your meals/snacks/beverages.

What are toxins now and past- food, chemical and environmental exposure?

Are you willing to make some changes? What do you envision as your best YOU emerging?

What motivates you, and what deters you from trying or completing tasks or goals?

How do you respond to being criticized? Assisted?

How frequently do you feel you need to review your progress to stay on track?

What methods help you learn most effectively?

How do you feel I can best support you throughout this relationship together?

Thank you for taking the time to complete this intake form. Your responses will remain confidential and will be used solely for the purpose of providing you with the best support possible. We look forward to working together to help you step into your power and live your fiercest life.