• Getting to know you

    A little about you and what brings you here.
  • What pronouns do you use?
  • How should I contact you about scheduling? (I only use phone or text for scheduling, never for personal details.)*
  •  -
  • What brings you to Interoception?*

  • Your life right now

    The people, demands and practical things that shape your week.
  • How supported do you feel by the people in your life?
  • What is taking up a lot of your energy right now? (Choose any that apply.)
  • What could make it harder to take part? (This helps me plan around real life.)

  • Your emotional well-being

    How you have been feeling lately and what helps. You can skip any optional question here and talk it through with me in person instead.

  • Over the past two weeks, how often have you…

    There are no right answers. This helps me understand where you are starting from, and whether coaching is the right fit or other support would serve you better.

  • Felt down, flat or low*
  • Felt worried or on edge*
  • Felt overwhelmed by stress*
  • Been very hard on yourself*
  • Had trouble sleeping*
  • Felt disconnected from people*
  • When things feel hard, what do you tend to do?
  • Have you worked with a counselor, therapist, psychologist or psychiatrist?
  • Would you be comfortable with me checking in with them? (Only ever with your written permission.)

  • Your physical well-being

    How you move, how your body feels, and a few safety questions. You can skip any optional question here and talk it through with me in person instead.
  • In a typical week, how active are you?*
  • Which kinds of movement do you enjoy, or would like to try?
  • Do you have pain, an injury or a physical limitation that affects how you move?*

  • A few safety questions before any physical activity

    Answering yes does not stop you from taking part. It means we will talk it through first, and I may suggest checking with your doctor before you increase activity.

  • Has a health provider ever told you to limit physical activity, or that you have a heart condition?*
  • Do you get chest pain, pressure or discomfort, during activity or at rest?*
  • In the past year, have you fainted, or lost your balance because of dizziness?*
  • Do you have a long-term condition (for example diabetes, asthma, high blood pressure, a joint condition) that affects activity?*
  • Are you pregnant, or have you given birth in the past six months?*
  • Do you take any medication a provider said could affect exercise?*

  • Your mind and body together

    How your feelings and your body affect each other. You can skip any optional question here and talk it through with me in person instead.
  • When you feel stressed or low, what tends to happen with your body or movement?
  • After you move your body, how do you usually feel?
  • How would you describe your relationship with your body right now?
  • Do any of these feel true for you? (Choose any that apply. These help me plan movement that feels safe for you.)
  • What would help you feel comfortable during physical activity?

  • Strengths and motivation

    What matters to you and what you bring with you.
  • Which of these strengths do you see in yourself?
  • Which matter most to you right now? (Choose up to three.)*
  • How important is it to you to make a change right now? (0 = not important, 10 = extremely important)*
  • How confident do you feel that you can make that change? (0 = not confident, 10 = extremely confident)*

  • Goals and preferences

    Where you would like this to go, in your own words.
  • What pace sounds right to begin with?*
  • Which kinds of sessions interest you?
  • How often could you realistically take part?

  • Safety, sharing and consent

    How I keep you safe and how your information is handled.

  • This form is not monitored in real time.

    If you are in crisis or thinking about harming yourself, call or text 988 (Suicide & Crisis Lifeline, US), call 911, or go to your nearest emergency department.

  • If it would help, may I share information with others involved in your care, such as your doctor, therapist or a trainer? (You can change this at any time.)*
  • Should be Empty: