Introductory Session intake form

1
Hi there! I look forward to helping you. Tell me your name.
First Name
Last Name
2
Email AddressWhat's the best email to reach you at directly?
example@example.com
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Phone Number
Area Code
Phone Number
4
What initially brought you to Lena's Community? *
5
What current struggles are you facing in your life that feel impossible to solve, or like a monkey on your back day in and day out no matter what you do? Please Be as detailed as possible* This field is required.*not enough time, tired, no energy, negative self talk, lack of motivation, pain, emotions, communication, asking for what you need, showing up for yourself, or others, etc.
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Have you worked with a coach, therapist, or healer before to help with these challenges?
YESNO
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what things have you tried to help move through these struggles and what was the outcome?
8
Do you have PMS? or Peri-menopause symptoms? If yes, What's the WORST part of PMS or your period for you?* This field is required.examples: negative mood, lack of motivation, pain, I feel off my game, cranky to my kids and/or partner/people around me, my body doesn't feel like my own
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Describe for me how these symptoms affect your daily life, work, relationships. Where does it go "wrong"? What do you want to change?* This field is required.
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Imagine we could work with your body to heal you physically, emotionally, mentally, what would life be like then?* This field is required.how would you feel? What would your schedule look like? What would you be able to do, you can't do now.
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Do you have any health concerns that would be helpful for me to know about?* This field is required.
12
Have you ever been given a mental health diagnosis? If yes, please share with me how you feel about the diagnosis.* This field is required.
13
Have you worked with a coach or therapist before? If so, what worked? What didn’t?
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Are you in a place to invest in your personal development and growth?
YESNO
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Have you experienced any physical or mental trauma?
YESNO
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If yes, I am so sorry that happened to you. If you feel comfortable, would you be willing to share if you’ve received therapy around the trauma? What type? And for how long? And where do you feel you are in the processing of this trauma?
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Thank you! Just click "submit" and your application is complete.

Thank you again for applying. I look forward to our call and how we can work together to help you.

See you soon,

Lena xoxo
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