Intake Form

This is a focused, intentional process designed to get a clear understanding of where you are and where you want to go.

Please allow approximately 20–30 minutes to complete this form.

All information is kept strictly confidential.

Please enable JavaScript in your browser to complete this form.

1Basic Information

2Your Issue

3More About You

4Health & Fitness

5Recent Changes

6Scheduling

First name *

Last name *

Date of birth *

Gender *

Email address *

Phone number *

You will receive a text message reminder the day before your appointment. Please follow the instructions to confirm your appointment promptly.

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Occupation *

Name of emergency contact *

Phone number of emergency contact *

Relationship to emergency contact *

Area of focus

What would you like help with? *

Briefly describe the main issue or goal (1–3 sentences).

How big of an issue is this in your life? *

Major
Moderate
Minor

What areas of life does this involve? *

Self-development
Health and fitness
Career
Relationships
Family
Purpose/spirituality

Do you consider this to be more of a problem or a goal? *

Problem
Goal

Select any of the following that apply: *

I need to reduce stress
I need to control a habit
I need to experience a professional breakthrough
I need to experience a personal breakthrough
I need to achieve a major goal
I need to transform my life

What’s MOST IMPORTANT to you about resolving this issue? *

Impact

What has this issue cost you so far? *

A lot
A little
Not much
Nothing

(Time, money, suffering, lost opportunities, sacrifice, etc)

What’s been its biggest cost to you? *

What have you previously invested in (or done) to help you with this? *

If this issue remains unresolved, what could it cost you over the next 5 years? *

A lot
A little
Not much
Nothing

Commitment and readiness

This is a structured, results-focused process requiring consistency, follow-through, and full engagement.

Are you ready to commit to doing what it takes to resolve this? *

What does that commitment look like for you? *

How committed are you on a scale of 1 to 10?

Selected Value: 10

10 = fully committed to doing what it takes

What would make this a 10? *

A key part of this process involves weekly reinforcement and completing simple daily assignments (e.g., listening to a short audio).

How consistent are you when it comes to following through on commitments? *

Very consistent — I follow through reliably
Mostly consistent — I follow through most of the time
Inconsistent — I start but don’t always finish
Struggle with consistency

Are you willing to follow through with simple daily reinforcement (e.g., a 10–15 minute audio)? *

the years?

Self-assessment

What are your main strengths? *

What are your main limitations? *

What are some accomplishments in your life that have meant the most to you? *

Current emotional experience

Which of the following challenging emotions (if any) have been most present for you recently?

Select all that apply:

Stress / Distress

Angry
Frustrated
Irritated
Resentful
Sad
Down
Hopeless
Depressed
Overwhelmed

Fear / Anxiety

Anxious
Nervous
Worried
Panicked
On edge
Insecure
Unsafe
Powerless

Self / Identity

Not good enough
Inadequate
Worthless
Guilty
Self-critical
Regretful

Relationships

Rejected
Abandoned
Unloved
Misunderstood
Lonely
Jealous

Energy / Motivation

Stuck
Unmotivated
Procrastinating
Burned out
Exhausted
Disengaged

Tension / Pressure

Tense
Pressured
Rushed
Impatient
Resistant

Which of the following positive emotions have been most present for you recently?

Select all that apply:

Calm / Regulation

Calm
Relaxed
Grounded
Centered

Confidence / Clarity

Confident
Capable
Certain
Clear

Energy / Engagement

Motivated
Focused
Engaged
Productive

Emotional Well-Being

Happy
Joyful
Grateful
Content

Connection / Openness

Connected
Loved
Appreciated
Open

Which of these positive states would you like to experience more consistently?

Which 1–3 emotions out of all your choices (positive and challenging) stand out as the strongest right now? *

Working style and preferences

How do you prefer to be worked with?

Select all that apply:

Communication style

Direct
Supportive and encouraging
Challenging and growth-oriented
Thought-provoking
Call me out when needed

Approach

Practical and results-focused
Flexible and adaptive
Structured and guided
Unconventional / outside-the-box

Tone / Presence

Calm and grounded
Energetic and engaging
Humorous
Serious and focused

Depth

Insightful / helps me understand myself
Strategic / helps me take action
Balanced (both insight and action)

Anything else that’s important to you in how you’re worked with?

Medical background

Name of primary care physician *

Physician’s phone number *

Are you currently receiving treatment from any healthcare providers (e.g., doctor, therapist, psychiatrist, etc.)? *

Please briefly describe anything relevant:

Are you currently taking any medications? *

Name and dosage of the medication:

Exercise

How often do you exercise? *

1-2 times a week
3-4 times a week
5-7 times a week
Infrequently
Never

What type(s) of exercise do you engage in? *

Sleep

How many hours of sleep do you require? *

What’s your normal bedtime? *

Do you have difficulty falling asleep? *

Do you have difficulty staying asleep? *

Diet, energy, stability

Which of the following do you consume regularly? *

Caffeine (coffee, energy drinks, pre-workout)
Alcohol
Sugary foods or drinks
Refined carbs (white bread, pasta, etc.)
Processed / fast food
Whole foods (fruits, vegetables, whole ingredients)
Supplements
None of the above

(Select all that apply)

How would you describe your energy and mental stability throughout the day? *

Stable and consistent
Some ups and downs
Frequent crashes or dips
Highly inconsistent / unpredictable

Which of the following do you experience? *

Cravings (sugar, caffeine, etc.)
Energy crashes
Brain fog or difficulty focusing
Irritability or mood swings
Feel shaky, anxious, or “off” when hungry
Rely on caffeine to function
None of the above

(Select all that apply)

Do you feel your diet noticeably affects your mood, focus, or energy? *

Yes, clearly
Somewhat
Not really
I’m not sure

Other considerations

Have any of the following ever applied to you? *

Panic or anxiety attacks
Ongoing depression (lasting more than a couple of weeks)
Difficulty controlling anger or impulses
Persistent intrusive or distressing thoughts
Thoughts of harming yourself
Past attempts to harm yourself
Thoughts of harming others
Hearing voices or seeing things others do not
Disordered eating behaviors (purging, extreme restriction, etc.)
Frequent emotional outbursts or conflict
Feel disconnected, isolated, or like an outsider
Sexual difficulties affecting well-being
None of the above

Recent life changes and stressors

Have you experienced any of the following in the past 6–12 months?

Select all that apply:

👤 Personal Life / Direction

Significant change in habits or lifestyle
Feeling uncertain about direction or purpose
Taking on something new (training, school, etc.)
Major decision about your future
Major personal disruption

🏥 Health

Personal health issue or injury
Health issue affecting someone close to you
Changes in alcohol or substance use

💼 Work / Financial

Job change or major shift in work
Increased work pressure or responsibility
Financial stress or income change
Starting or changing a business

🏠 Living situation

Change in living situation (move, new household, etc.)

👥 Relationships

Major relationship change (breakup, separation, divorce)
New relationship
Ongoing conflict in a close relationship
Loss of someone close (family, friend, partner)
Birth or adoption of a child

⚖️ Other stressors

An accident
Loss or damage to property
Legal issues

⚡️ Overall stress load

Multiple significant changes happening at once
Ongoing stress that hasn’t let up

Which of these has had the biggest impact on you?

Scheduling policy

Sessions are part of a structured program and are reserved in advance, exclusively for you.

Sessions may be rescheduled with at least 24 hours notice.

Appointments cancelled or changed with less than 24 hours notice—as well as missed appointments—will be forfeited.

Consistency supports the best results in this work.

Enrollment in a payment plan does not change this policy. Program fees are based on the full program commitment, not session attendance.

Additional sessions beyond the program are available upon request and are billed separately.

Checkboxes *

I understand and agree to the scheduling policy above.