Private SessionsIntake Form Name * First Name Last Name Email * Phone (###) ### #### Why are you interested in coaching? * What are your goals/what are you hoping to achieve from coaching? * Which areas do you want support around? Select all that apply? * Nutrition Gut Health Nervous System Regulation Attachment Styles Dating/Romantic Relationships Other Types of Relationships Mindset & Motivation What is your biggest problem right now? * On a scale of 1-10, how would you rank your overall life satisfaction right now? * 1 2 3 4 5 6 7 8 9 10 On a scale of 1-10, how would you rank your job/career right now? * 1 2 3 4 5 6 7 8 9 10 On a scale of 1-10, how would you rank your physical health right now? * 1 2 3 4 5 6 7 8 9 10 On a scale of 1-10, how would you rank your mental & emotional health right now? * 1 2 3 4 5 6 7 8 9 10 On a scale of 1-10, how would you rank your familial relationships? * 1 2 3 4 5 6 7 8 9 10 On a scale of 1-10, how would you rank your friendships? * 1 2 3 4 5 6 7 8 9 10 On a scale of 1-10, how would you rank your romantic life? * 1 2 3 4 5 6 7 8 9 10 Anything you want to elaborate on? * What does your diet look like? What's a typical day of eating for you? * Do you have any of these symptoms? Check ALL that apply! * low energy low mood acne low libido anger irritability intrusive thoughts feelings of panic feelings of sadness insecurities often wonder whether people like me loneliness water retention gassiness constipation diarrhea bloating excess body weight difficulty losing or maintaining weight difficulty sleeping or frequent waking difficulty getting up dull skin hair loss or dry brittle hair overthinking frequent meltdowns feel like a burden feel like a failure feel like a fraud Are there any other symptoms you experience that were not listed? Describe them here * Is there anything else you want to tell me? * Thank you! I look forward to our session!