Private & Confidential Intake Form

Thank you for your interest in working with us! We are grateful for your consideration. As a precursor to our meeting, we ask that you fill out this simple intake form. It is confidential (as are all of our communications with you) and will help us get a better sense of you and your concerns.

PLEASE NOTE: This form will not be saved if you stop mid thought and close this page. If you would like to print out a document to take your time filling this out, please download below:

Download Intake Form

Name

First Name

Last Name

Date of Birth Month/Year. What is your gender identity

Cell Phone

(###)

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Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

What changes do you want to see in your life?

When were you happiest? Describe the time and circumstances. How do you feel now looking back?

Think of one challenge/difficulty from your past that you overcame - what carried you through? What did you learn about yourself?

What is your current resource network like? People? Places? Pets? Teachers?

What kind of body/mind practices do you have right now?

How are you sleeping?

Do you consider yourself a resilient person? Why or why not?

Tell us about your fitness practices:

Do you have any health issues? If yes, please describe briefly.

Is it easy or difficult for you to feel self-compassion when something goes wrong?

How is your anxiety and stress and what are your triggers?

Are you feeling depressed?

What are your creative outlets?

What makes you happy?

Are your relationships satisfying and healthy?

Are you currently working?

Do you enjoy your work?

What do you want more of in your life?

What do you want less in your life?

What are the biggest changes you want to make in your life in the next few years?

What is keeping you from making these changes?