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About Me
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Who is it for?
The Body & the Elements Course
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Intake Form
Blog
Home
About
About Me
The Process
Fee structure
Contact Me
Services
Coaching Containers
Who is it for?
The Body & the Elements Course
Schedule
Forms
Intake Form
Blog
Forms
Intake Form
Name
*
First Name
Last Name
Email
*
Phone
*
(###)
###
####
Is it ok to communicate via text and/or email?
*
Yes
No
Is it ok to leave a voicemail message if you cannot be reached?
Yes, but please leave a general message only
Yes, a detailed message is fine
No, please do not leave a voicemail message
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Preferred contact method
Phone
Email
Text
I confirm that I am an adult (18 years of age or older) and am able to provide my own consent to services.
*
Yes
No
Please list the name and phone number of an emergency contact.
Gender & Pronouns
What are some of your goals for our work?
Do you have any accessibility needs you want me to know about?
Are there any religious or cultural needs/preferences you would like me to know about?
Do you have any physical or mental health conditions? If yes, please specify.
Do you have any allergies? If yes, please specify.
Do you have a history of or any current concerns with eating disorders and/or disordered eating? If yes, please explain.
Do you have a current medical practitioner? If so, who?
Please list any medications and/or supplements you are currently taking.
Have you worked with other healing professionals in the past? If yes, please explain.
Please describe the type, duration, and frequency of your current physical activity.
Do you experience stress that you find impacts your functioning? If yes, please explain.
Do you feel you have sufficient social supports? Please explain.
How would you say your sleep has been feeling lately?
Have you followed a particular diet in the past, or do you currently follow a specific diet? If yes, please explain.
Do you feel there are any barriers to being able to eat nourishing foods? If yes, please explain.
Do you feel there are any barriers to reaching your health and wellness goals? If yes, please explain.
What are some of your favorite self-care tools or activities? What brings you joy?
Thank you!
