Program Intake Form

Thank you for taking the time to fill out the following questions. Please complete prior to your first session.

All of your information that you share is private and confidential.

If you want to complete the PDF form instead please click the link below.
(Requires a PDF reader, and more than likely not available on mobile devices)
Intake Form

Name *

Email *

Phone *

1. What are your main concerns (related to your health & lifestyle)?

2. What have you done in the past to work on these concerns? (include both alternative and traditional modalities.)

3. What has proven effective?

4. What is your current diet like? Please be specific; list breakfast, lunch, dinner, and snacks, as well as the times you eat.

5. What hobbies do you have, things you like to do in your free time?

6. Do you attend a gym, or have an existing exercise routine in place?

7. Are you taking any OTC/supplements? Please list what you take and what it is for.

8. Are you taking any medication prescribed by your doctor? Please list what you take and for what health concern.

9. What would you like your health or lifestyle to be 30 days from now? How about 90 days from now? How would you feel if you got this result?

10. What obstacles, challenges, and struggles do you come up with regarding diet/lifestyle?

11. What do you hope to get out of our time together?

12. What are 5 things you LOVE about your life?

Message

Program Intake Form

Thank you for taking the time to fill out the following questions. Please complete prior to your first session.

All of your information that you share is private and confidential.

GO DREAM • GO DO • GO BECOME