Stoked Life Self-Care Client Form

Name

First NameLast Name

Phone Number

International Area CodePhone Number

E-mail

Gender

MaleFemaleOther

Age

Occupation

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

How did you hear about STOKED LIFE?

EMERGENCY INFORMATION

Emergency Contact's Name

First NameLast Name

Relationship

Emergency Contact's Phone Number

International Area CodePhone Number

YOUR CURRENT STRESS IN LIFE

What level of stress are you currently experiencing in life?

	1	2	3	4	5	6	7	8	9	10

1 is Nil, 10 is I am completely overwhelmed

List the main things that cause you stress:

What is your 'go to' thing that you do in order to relieve your stress:

Feel free to list more than one strategy you use to relieve stress if you have more than one.

YOUR CURRENT SELF-CARE PRACTICE

How would you describe your current self-care practice?

What types of self-care practices do you currently do?

	Do you do this activity?	If so, how often?	Whether you do this activity or not, do you enjoy this activity?
Eat healthy
Exercise
Meditation
Yoga
Journalling
Art
Take baths
Set aside time to hang with friends
Set aside time to hang with family
Dance
Play an instrument
Listen to podcasts
Read
Create Vision Boards
Other
Nothing I can think of

What is your favourite self-care activity to do (even if you don't do it often) & why?

If you meditate regularly, please describe what this typically looks like, the approximate frequency & duration that you usually practice:

If you exercise regularly, please describe what type of exercise you do, the approximate frequency & duration that you usually do:

How do you express your creativity?

On average, how many hours per day do you watch TV

What do you consider to be your greatest challenge/s in regards to your ability to practice self-care consistently?

Do you have any injuries, limitations or other health concerns that may interfere with your ability to practice self-care activities that I should be aware of? e.g. a knee injury that may require a different seated position for your meditation practice

NoYes

If yes, please provide details below:

Please list any health concerns I should be aware of.

YOUR LIFE DISLIKES AND LOVES

List the SIX things in your life that you enjoy doing THE LEAST

	Thing you do not like doing	How often you do it	Do you have any wriggle room to either stop doing this activity [or at least reduce the frequency in which you do it]?	If you have to keep doing this activity despite not wanting to, WHY?
I do not enjoy:
I do not enjoy:
I do not enjoy:
I do not enjoy:
I do not enjoy:
I do not enjoy:

List TEN things in your life that bring you happiness or joy? [these can be experiences, things, people, free or something that costs you money]

	Thing you LIKE doing	How often you do it	Would you be able to experience this thing more regularly]?	What things block or reduce your ability to experience this thing?
I love:
I love::
I love:
I love:
I love:
I love:
I love:
I love:
I love:
I love:

How do you personally block or limit the flow of joy or happiness into your life?

What do you think you NEED to change or do in order to be in a position that welcomes more joy and happiness in your life?

How will you know you are feeling more joyful, energized and happy in your life?

What is your main purpose or desired outcome for your self-care work with Jess?

CANCELLATION POLICY

Please note a cancellation fee of $40 applies if there is less than 24 hours notice.

REFUND POLICY

To receive the best value I ask you to commit to all 4 sessions. However, if - after paying for the full package - you come to the first session and for some reason do not wish to continue, a refund for the remaining sessions will be offered.

CLIENT STATEMENT

By signing this form you are declaring that:

You have carefully read & understood the Cancellation & Refund Policies.
You understand and acknowledge that self-care & meditation practices are known to support mental and physical wellbeing, and to relieve stress. You understand they do not replace medical care. STOKED LIFE does not diagnose, prescribe or medically treat any condition or disorder.
STOKED LIFE does not provide psychological counselling and/or talk therapy for specific mental health issues or traumas.
You understand to get the maximum gain from your sessions, it is recommended that you rearrange your priorities outside of your sessions to accomodate your self-care & meditation practice [you need to allow approx. 15 - 30 mins most days, or at a minimum twice per week].
You understand all Stoked Life resources are not to be distributed to anyone unless you have acquired permission to do so from Jess Simson.

SIGNATURE

This statement is being signed voluntarily.

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

Name

First NameLast Name

Date

Thank you so much for taking the time to complete this form. I can't wait to work together!!!

Self-care