Client Intake Form

Name

First Last

Email

Phone

When it comes to your nutrition, please check all that apply to you*

My nutrition and eating habits are a hot mess
I eat a variety of foods each day, including seven or more servings of fruits and vegetables, depending on my calorie intake
I avoid skipping meals
I can't seem to stick to something long enough to see results.

When is comes to exercise and fitness, please check all that apply to you.*

I don't exercise at all
I have no idea where to start.
I engage in moderate-intensity exercise 2 or more times per week.
I maintain a healthy weight, avoiding being overweight or underweight.

Let's talk emotional health. Check all that apply to you.*

I find it easy to relax and express my feelings freely.
I manage stress well.
I stress way too much on a daily basis
I feel I have I have lost myself and who I used to be.

Please rate the following on a scale of 1 to 10 with 10 being the highest level of wellness and 1 being the lowest

Physical wellness*

Emotional/Mental Wellness*

Spiritual Wellness*

Interpersonal/social wellness*

Environmental wellness*

Please tell me a little bit about what you would like to address on our one on one call. The more specific you are, the better we can come up with a plan for you.*

Please take a few minutes to fill out this form below before our call

Client Intake Form

Please rate the following on a scale of 1 to 10 with 10 being the highest level of wellness and 1 being the lowest