4-Week Journey Intake Form
Help us tailor your 4-week journey by sharing your motivations, habits, and hopes. Please answer honestly so we can best support your individual needs.
Welcome! This intake form is designed to help us understand your unique goals, challenges, and preferences for your 4-week journey. Your honest responses will allow us to provide the most relevant support and resources. All information is confidential and used only to personalize your experience.
What are your main motivations for signing up for this journey? (Select all that apply)
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Increased energy
Better sleep
Brain health
Hormone balance
Curiosity
Other (please specify)
What is your biggest daily challenge where you’d like more support?
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Brain fog
Mood changes
Digestion issues
Low energy
Sugar cravings
Inflammation
Memory concerns
Sleep problems
Which best describes your current eating habits?
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Mostly whole, unprocessed foods
Balanced but includes some processed foods
Frequent takeout or convenience foods
Irregular meal patterns
Following a specific diet (e.g., vegan, keto, etc.)
Other
Which statements best describe your movement and creativity habits? (Select all that apply)
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I move my body daily (walk, stretch, exercise, etc.)
I move a few times a week
I need motivation to move more
I regularly engage in creative activities (art, music, writing, etc.)
I want to be more creative
Other (please specify)
Describe the changes you hope to experience during this 4-week journey.
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Is there anything else you’d like us to know to better support you? (Optional)
Interested in adding a private upgrade? Includes a detailed intake, a 1-hour private session, and a written set of personalized recommendations.
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Yes
No
Name
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First Name
Last Name
Email
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example@example.com
Submit Intake
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