self_love_intake

Self Love Consultation Intake Form

Thank you for choosing to invest in yourself. Please take a few minutes to answer these questions honestly and thoughtfully. Your responses will help me understand your journey and how I can best support you.

1. Full Name

2. Email Address

example@example.com

3. Phone Number (optional)

Format: (000) 000-0000.

4. Gender: Woman, Self-describe, Man, Non-binary

5. Occupation (optional)

6. What inspired you to book a self love consultation?

7. What areas of self love or self care do you feel most confident in?

8. What areas do you find most difficult ex boundaries body image self talk confidence healing?

9. What is your biggest goal or hope for working together?

10. On a scale of 1-10 how would you rate your overall emotional wellbeing right now?

11. What emotions or thoughts do you find yourself experiencing most often?

12. Do you have a history of trauma or experiences you would like me to be aware of while working with you? Prefer not to say (If yes and you're comfortable, please share only what feels safe)

13. What type of support feels most helpful for you? Gentle guidance & encouragementAccountability & structure Tools & exercises for daily practice A safe space to share and process.

14. Is there anything specific you would like me to avoid during our sessions?

15. Is there anything else you would like me to know about you before we begin?

Thank you for sharing. This information will remain confidential and is only used to support you in your self love journey.