Intake Assessment

These questions are designed to make you stop and reflect so please take your time. If there is a question that you're having trouble answering, skip it and come back to it before you press submit. If you feel there are repetitive questions you can either go deeper or just refer to a previous answer. I appreciate your willingness to share yourself with me and look forward to getting to know you.

Name *
Name
Phone *
Phone
Rate how well each health & wellbeing statement describes you, then provide details in the text box below.
Fitness: I feel healthy and am happy with the physical condition I'm in.
Fitness: I feel healthy and am happy with the physical condition I'm in.
Nutrition: My diet is exactly where I want it.
Nutrition: My diet is exactly where I want it.
Sleep: I get a straight 7-8 hours of uninterrupted sleep every night.
Sleep: I get a straight 7-8 hours of uninterrupted sleep every night.
Stress: The amount of stress I'm under is about average and I manage it well.
Stress: The amount of stress I'm under is about average and I manage it well.
Body Image: When I look in the mirror I feel content and grateful for the body I have.
Body Image: When I look in the mirror I feel content and grateful for the body I have.
Self Care: I regularly take "me time" to nurture myself.
Self Care: I regularly take "me time" to nurture myself.
Alcohol (or other substance): I have a healthy relationship to alcohol/substance and practice moderation.
Alcohol (or other substance): I have a healthy relationship to alcohol/substance and practice moderation.
Pain: My body feels good most of the time and I rarely hurt.
Pain: My body feels good most of the time and I rarely hurt.
Energy: I have a zest for life and balanced energy throughout the day.
Energy: I have a zest for life and balanced energy throughout the day.
Mindfulness: I am aware of my thoughts and actions and typically feel nonjudgmental towards myself.
Mindfulness: I am aware of my thoughts and actions and typically feel nonjudgmental towards myself.
Personal Growth: I am always learning new things and developing as a person.
Personal Growth: I am always learning new things and developing as a person.
Relationship/ Romance: I am fulfilled by my current relationship status.
Relationship/ Romance: I am fulfilled by my current relationship status.
Friends: I have people in my life who I trust, care about, have fun with and can be myself around.
Friends: I have people in my life who I trust, care about, have fun with and can be myself around.
Family: I love and respect my family and know they love and respect me.
Family: I love and respect my family and know they love and respect me.
Finances: The amount of money I have gives me a feeling of security and freedom.
Finances: The amount of money I have gives me a feeling of security and freedom.
Physical Environment: I am happy with my town and the home I live in.
Physical Environment: I am happy with my town and the home I live in.
Career: The work I do uses my strengths and suits me well
Career: The work I do uses my strengths and suits me well
Fun & Recreation: I know how to "play" and enjoy myself.
Fun & Recreation: I know how to "play" and enjoy myself.
If something else comes to mind later, you can always send an additional email.