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Creating Calm App
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About
Free Resources
Podcast
Creating Calm App
Work With Me
Speaking & Media
Contact
New Client Intake Assessment Form
What's your name?
How would you rate your stress in the past three months?
Extremely high
Very High
Somewhat High
Moderate
Low
I'm not feeling stressed at all
When you experience stress, how do you typically respond?
Fight (angry, aggressive or frustrated)
Flight (avoid, self-medicate or other methods of escape)
Freeze (feeling stuck, overwhelmed, or numb)
Fawn (people-pleasing, or compliance)
When you're feeling run down, how easy is it for you to recover your energy?
Easy
Manageable
Difficult
Very Difficult
What are your primary sources of stress and/or burnout? (please select all that apply)
Work
Family
Friends
Significant Other
Health
School/Education
Finances
Self-talk/Inner Critic
Anxiety
Other
Why are you looking to work with me one-on-one?
What have you tried so far to relieve this issue on your own?
On a scale of 1 to 10 with 10 being the highest, where would you rate your satisfaction with your physical health?
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On a scale of 1 to 10 with 10 being the highest, where would you rate your satisfaction with your mental health
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On a scale of 1 to 10 with 10 being the highest, where would you rate your satisfaction with your family interactions?
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On a scale of 1 to 10 with 10 being the highest, where would you rate your satisfaction with your friend interactions?
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On a scale of 1 to 10 with 10 being the highest, where would you rate your satisfaction with your finances?
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On a scale of 1 to 10 with 10 being the highest, where would you rate your satisfaction with the amount of playfulness in your life?
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On a scale of 1 to 10 with 10 being the highest, where would you rate your satisfaction with your responsibilities and routines?
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On a scale of 1 to 10 with 10 being the highest, where would you rate your overall alignment with your mission and values?
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On a scale of 1 to 10 with 10 being the highest, where would you rate your satisfaction with your career?
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Anything else that you'd like me to know before our first session?
Submit
