Client Assessment Form

Client Assessment Form

Fill this form out to supply Faith with the information she needs to give you the most personalized, delightful service.
Today's Date

MonthDayYear
Date
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Desired Start Date

MonthDayYear
Date
How many members are in your household?
Emergency Contact Name
Emergency Contact Number
Please enter a valid phone number.Format: (000) 000-0000.
YesNo
What are some challenegs you face with healthy eating?

How many hours per week do you spend on the following?
How much on average do you spend on groceries per week?
How much on average do you spend on eating out per week?
What did you eat for lunch/dinner this week?
How often do you eat out in a week?
Some favorite restaurants?
How often do you eat dessert? What are some of your favorites?
What are some recipes you love and want me to prepare for you?
Would you like me to ingredient meal prep for you (prepare and store all ingredients separate so you can put together meals with variations of the ready to go ingredients)?

Do you have a fire extinguisher? If yes, where?
Where is your fuse box located?
Where are trash and recycling containers located?
Security arrangements necessary for Chef Faith to enter your home on your cook date.
Do you have children that live with you full or part time? If so, how many and what are their names and ages?
Names and birthdays of all household members.
Do you have any pets? How many?
List their names, breeds, and if they are indoor and/or outdoor pets.
YesNo