Precision Transformation Experience - Initial Discovery Questionnaire

Full Name* This field is required.

First Name

Middle Name

Last Name

Date of Birth* This field is required.

Date

Email Address* This field is required.

example@example.com

Phone Number* This field is required.

Please enter a valid phone number.

Emergency Contact Name* This field is required.

First Name

Middle Name

Last Name

Describe yourself in your own words* This field is required.

What do people often misunderstand about you?

Three words that describe you today* This field is required.

Three words that describe you in 5 years* This field is required.

What have been the biggest impacts in your life so far?* This field is required.

If your life were a movie, what would its title be?

What chapter of life are you in right now?* This field is required.

When did life change for you?

Date

Hope* This field is required.

Very low

Very high

Happiness* This field is required.

Anxiety* This field is required.

Stress* This field is required.

Confidence* This field is required.

Motivation* This field is required.

Energy* This field is required.

Self-worth* This field is required.

Briefly explain your current emotional state

What thoughts or concerns keep repeating in your mind?

What worries are on your mind most often?

What tends to keep you awake at night?

How would you describe your self-talk?

How would you rate your overall health?* This field is required.

Excellent

Very good

Good

Fair

Poor

How would you describe your sleep quality?* This field is required.

Very good

Good

Fair

Poor

Very poor

How is your daily energy level?* This field is required.

Very high

High

Moderate

Low

Very low

What medications do you currently take?

None

Prescription medications

Over-the-counter medications

Topical medications

Hormonal medications

Other

What supplements do you currently take?

None

Multivitamin

Vitamin D

Omega-3

Protein supplement

Herbal supplement

Other

How often do you drink alcohol?* This field is required.

Never

Monthly or less

2-4 times a month

2-3 times a week

4 or more times a week

Have you ever used recreational drugs in the past?* This field is required.

Yes, in the past

Prefer not to say

Do you currently use recreational drugs?* This field is required.

Yes

Prefer not to say

Do you have any current or ongoing medical conditions?

Relationship with self* This field is required.

Relationship with mother

Relationship with father

Relationship with brother

Relationship with children

Relationship with friends

Most painful relationship

Natural strengths* This field is required.

Communication

Problem-solving

Creativity

Empathy

Leadership

Organization

Adaptability

Resilience

Other

A proud moment that showed your strengths

Interests and activities that energize you

Reading

Exercise

Art/Design

Music

Cooking

Nature/Outdoors

Learning

Volunteering

Socializing

Other

Which habits or behaviors are currently getting in your way?

Procrastination

Overthinking

Poor sleep routine

Stress eating

Negative self-talk

Difficulty setting boundaries

Inconsistent exercise

Too much screen time

Other

What are the biggest barriers preventing progress right now?

What would success look like for you in 6 months?* This field is required.

What would success look like for you in 1 year?* This field is required.

What would success look like for you in 5 years?* This field is required.

How ready are you to begin this transformation process?* This field is required.

What would increase your readiness?

Are you currently thinking of harming yourself or someone else?* This field is required.

Yes

Welcome — there are no right or wrong answers. Your responses will help personalize the first session, and this form is not a diagnosis or emergency service.