New Client Intake 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
How much time do you spend per week taking care of yourself?
Does sleep count?
Who has time for that?
Not a lot
Some
At least 30-minutes per day
I'm a self-care superstar!
What are your primary sources of stress and/or burnout? (please select all that apply)
Work
Family
Friends
Significant Other
Health
School/Education
Self-talk/Inner Critic
Anxiety
Other
What have you tried so far to help you with your stress and burnout?
On a scale of 1 to 10 with 10 being the highest, where would you rate your satisfaction with your physical health?
1
2
3
4
5
6
7
8
9
10
On a scale of 1 to 10 with 10 being the highest, where would you rate your satisfaction with your mental health
1
2
3
4
5
6
7
8
9
10
On a scale of 1 to 10 with 10 being the highest, where would you rate your satisfaction with your skills development and personal learning curriculum?
1
2
3
4
5
6
7
8
9
10
On a scale of 1 to 10 with 10 being the highest, where would you rate your satisfaction with your family interactions?
1
2
3
4
5
6
7
8
9
10
On a scale of 1 to 10 with 10 being the highest, where would you rate your satisfaction with your friend interactions?
1
2
3
4
5
6
7
8
9
10
On a scale of 1 to 10 with 10 being the highest, where would you rate your satisfaction with your finances?
1
2
3
4
5
6
7
8
9
10
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?
1
2
3
4
5
6
7
8
9
10
On a scale of 1 to 10 with 10 being the highest, where would you rate your satisfaction with your responsibilities and routines?
1
2
3
4
5
6
7
8
9
10
On a scale of 1 to 10 with 10 being the highest, where would you rate your overall alignment with your mission and values?
1
2
3
4
5
6
7
8
9
10
On a scale of 1 to 10 with 10 being the highest, where would you rate your satisfaction with your career?
1
2
3
4
5
6
7
8
9
10
Why are you looking to work with me one-on-one?
What would you like me to know before our first call?
Submit