Intake Questionnaire

Intake Questionnaire
Please share as much as you are comfortable about you and your story. There are no right or wrong answers here — just share what you feel is important so I can enter our relationship with a better understanding of who you are. Feel free to fill out as much or as little as you want, but keep in mind that the more open you're willing to be, the more effectively I'll be able to support you!
Name*

First NameLast Name
Email*
Please enter a valid email address.
Phone Number*
Please enter a valid phone number.
Date of Birth

MonthDayYear
Date
Gender
Please select your gender.
Location
City, State/Province
Career/Occupation
I'd like to heal/experience LESS:*

Health challenges/symptomsTiredness/fatigueAnxietyDepressionEmotional/binge eatingLack/scarcity/never having enoughFear of the future/unknownInsecurity/self-doubtFeeling unworthy/not good enoughGuilt/shamePerfectionismPeople-pleasingIndecisionSelf-criticismComparison/jealousyPast trauma/unresolved emotionsOverthinking/emotional avoidanceStressSelf-sabotage/not chasing my dreamsBurnoutNot believing it's possible for meOther (please specify)
Any other conditions or medical diagnoses I should be aware of?

YesNo
Please list them.
Please provide any relevant information regarding your health condition/s.
I'd like to experience MORE:*

Health/vitalityLoveHappiness/joyAbundance/wealthSuccess/prosperityConfidenceSelf-worthConnection in my relationshipsSense of purpose/fulfillmentConnection to God/universe/a higher powerInner freedomPeace/stillnessTrust in self/others/lifeClarity about the futureSelf-understanding/awarenessOther (please specify)
If this could be the best year of your life, where would you be 12 months from now?*
What do you feel is holding you back from achieving your long-term and short-term goals?*
How can I most effectively support you in overcoming these blocks and creating the life you desire?*
What are 3 of the most unkind things that you regularly say to yourself?*
e.g. "I'm not smart enough", "I always screw things up", "Nothing ever goes my way", etc.
Looking back at times you’ve succeeded, what specifically helped you get there and made you feel supported?
Tell me about a breakthrough or insight you've had recently.
What motivates you and inspires you to keep moving forward?*
Is there anything else you'd like me to know before we begin?
e.g. recent hardships, major life changes, desired support style, etc.
Should be Empty: