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- When were you born?*
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- Which best describes your current relationship status?*
- Do you currently care for children, family members, clients, patients, or others on a regular basis?*
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- Which best describes your current work environment?*
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- How would you describe the overall pace of your daily life right now?*
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- Which areas of your life currently feel the most demanding? (Select all that apply.)*
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- How would you describe the season of life you're currently in?*
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- What would you love to experience more of in your daily life? (Select all that apply.)*
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- What time do you typically wake up?*
- What usually determines when you wake up?*
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- What time do you typically go to bed?*
- About how long does it usually take you to fall asleep?*
- About how many hours of sleep do you typically get each night?*
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- How soon after waking are you typically exposed to outdoor or natural light?*
- Do you typically consume caffeine?*
- If yes/ most days/ occasionally… About how long after waking do you usually have your first caffeinated drink?
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- Around what time do you typically have your first meal or caloric drink of the day?*
- Around what time do you typically finish your last meal or caloric drink of the day? *
- How many meals do you typically eat in a day?*
- Approximately how much water and other non-caffeinated fluid do you drink in a typical day? (Assuming roughly 8 oz per glass)*
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- During a typical day, how long do you usually remain in one position before naturally changing position or moving around?*
- How often is intentional movement or exercise currently part of your life?*
- What kinds of movement are currently part of your life? (Select all that apply.)*
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- About how much time do you typically spend outdoors in a day?*
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- How close to bedtime are you typically using a phone, television, computer, or tablet?*
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- When during the day do you generally feel your best?*
- Do you notice predictable times when your energy, focus, mood, or motivation drops?*
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- How often does your day feel rushed?*
- How much genuine pause exists in an average day - time when nothing is immediately required of you?*
- How often are you able to notice and respond to basic needs - such as hunger, thirst, needing the bathroom, fatigue, movement, or rest - when they arise?*
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- If one part of your typical day could feel easier or more supportive, which part would you choose?*
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- When life feels demanding or stressful, which of these responses are familiar to you?*
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- When you’re under pressure, what tends to happen in your body first?*
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- How quickly do you usually recognize that you’re becoming stressed, overwhelmed, or overloaded?*
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- How much of the time do you currently feel like your system is “on” - anticipating, managing, solving, responding, or staying prepared for what comes next?*
- How easily can you shift out of “doing mode” when there is nothing you need to handle?*
- After something stressful or upsetting happens, how long does it usually take before you feel more like yourself again?*
- When several demands happen at once, what best describes your experience?*
- When plans change, something doesn’t work, or you make a mistake, how easily are you able to adjust and try another approach?*
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- When you notice that your body needs something, how much freedom do you usually have to respond to it?*
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- How often do you experience moments when your body feels genuinely settled - not necessarily sleepy, but able to soften without needing to stay alert or productive?*
- How comfortable is it for you to rest when there is still something that could be done?*
- Which statement feels closest to your experience of support from other people?*
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- Overall, how would you describe your nervous system capacity right now - your ability to experience stress, emotion, change, or challenge without becoming overwhelmed or depleted?*
- Which statement best describes what you feel you need more of right now? (Select up to 3.)*
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- How long have your primary concerns been present?*
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- How would you describe the overall pattern of what you’re experiencing? (Select all that apply.)*
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- Which of these are familiar to you? (Select all that apply.)*
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- Which best describe the way your body experiences temperature? Select all that apply.*
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- How would you describe your appetite most days?*
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- After eating, how do you usually feel? (Select all that apply.)*
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- Which digestive experiences do you notice with any regularity? (Select all that apply.)*
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- How often do you typically have a bowel movement?*
- Which best describes your bowel movements most often?*
- Do you regularly notice any of the following? (Select all that apply.)*
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- Do you regularly notice any of the following?(Select all that apply.)*
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- How would you describe the quality of your sleep most nights?*
- Which sleep patterns are familiar to you? (Select all that apply.)
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- Do you currently experience recurring pain, stiffness, tension, restriction, numbness, tingling, or other physical discomfort?*
- If yes/ occasionally… Where do you notice it? (Select all that apply.)*
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- How would you describe what you feel? (Select all that apply.)*
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- Which changes do you currently notice in your skin, hair, or nails? (Select all that apply.)*
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- Which of these have been part of your experience recently or recurrently? (Select all that apply.)*
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- Which best describes your current reproductive or hormonal stage?*
- If currently menstruating/ cycles are changing…How would you describe your menstrual cycle? (Select all that apply.)*
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- If perimenopausal/ menopausal/ post menopausal…Which changes have you noticed during this transition? (Select all that apply.)*
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- Are you currently pregnant, breastfeeding, trying to conceive, or is there any possibility you may be pregnant?*
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- Of everything you’ve described, which 3 areas currently have the greatest impact on your quality of life? (Select up to 3)
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- When you think about your relationship with your body right now, which words feel most accurate? (Select all that apply.)*
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- When your body does something you don’t understand or don’t want, what is your first internal response most likely to be? (Select up to 3.)*
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- When your own experience of your body differs from what someone else tells you should be happening, which response feels most familiar?*
- How confident do you currently feel distinguishing between what genuinely works for your body and what you believe you should be doing?*
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- Which of these statements feel familiar in the way you care for yourself? (Select all that apply.)*
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- When you miss a workout, eat differently than planned, skip a wellness practice, or otherwise don’t follow your intended routine, what tends to happen internally?*
- How much pressure do you currently place on yourself to improve, change, heal, perform, or “get it right”?*
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- How would you describe your relationship with your physical appearance right now?*
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- When you move without instructions - stretching, shifting position, dancing, rolling, reaching, or simply following what feels good - how comfortable is that for you?*
- How comfortable are you generally receiving supportive touch or bodywork?*
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- How easy is it for you to communicate when something being done doesn’t feel right in your body?*
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- Which statement best describes where you would like your relationship with your body to move from here? (Select up to 3.)*
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- Which kinds of sensory experiences do you naturally enjoy or seek out? (Select all that apply.)*
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- How do you generally respond to aromas and scented products?*
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- Which flavors do you naturally enjoy? (Select all that apply.)*
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- Are there sensory experiences that tend to feel especially uncomfortable, irritating, overwhelming, or physically unpleasant for you? (Select all that apply.)*
- Do any sensory or environmental exposures cause noticeable physical symptoms for you? . Examples might include headache, migraine, nausea, dizziness, coughing, congestion, skin reactions, breathing discomfort, fatigue, brain fog, or feeling suddenly unwell.*
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- When you want to change how you feel - whether you’re stressed, tired, bored, uncomfortable, lonely, overstimulated, under-stimulated, or simply wanting a little pleasure - what do you tend to reach for? (Select all that apply.)*
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- When you reach for these things, what are you usually hoping they will help you experience? (Select all that apply.)*
- How much choice do you generally feel you have around these patterns?*
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- Are there any habits or behaviors in your life right now that you would like to change, reduce, understand better, or feel more choice around?*
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- Have you ever intentionally changed, reduced, or stopped a habit that had become important to you?*
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- What reliably helps you feel more grounded, restored, energized, connected, or simply more like yourself? (Select all that apply.)*
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- When you notice that you’re becoming stressed, depleted, overwhelmed, or disconnected, how often do you actually use the things you know help you?*
- What most often gets in the way of doing the things that help you feel well? (Select all that apply.)*
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- How supported do you generally feel by the people in your life?*
- When you genuinely need help or support, how comfortable are you asking for and receiving it?*
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- When learning something new about your body or well-being, what helps you understand it best? (Select all that apply.)*
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- When making changes, which approach tends to work best for you?*
- How much information do you generally prefer when receiving recommendations about your well-being?*
- What kind of accountability or follow-through support tends to work best for you?*
- When someone offers guidance about your body or well-being, what helps that guidance feel supportive rather than overwhelming or restrictive? (Select all that apply.)*
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- How much room does your life realistically have for making changes to your well-being right now?*
- What currently affects how much capacity you have to focus on your well-being? (Select all that apply.)*
- When you think about making changes right now, which statement feels most true?*
- If we identified several areas that could support your well-being, what would feel most manageable to begin with?*
- How much time could you realistically devote to supporting your well-being on most days?*
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- Which areas of your well-being are you most interested in exploring or learning more about? (Select all that apply.)*
- Which types of support or experiences are you curious about exploring? (Select all that apply. You do not need to know exactly what any of these involve yet.)*
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- Which qualities would you most love to experience more often as you move through your life? (Select all that apply.)*
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- Should be Empty: