Client Intake Form

welcome! i'm so happy to be working with you.

Client Intake Form

Please answer honestly and to the best of your ability. There are no right or wrong answers. If the question is not relevant to you simply state N/A.

Briefly describe your dream life.

Briefly describe what specific mindset challenges (beliefs, fears, internal dialogue etc) have prompted you to work with me?

How are these challenges impacting your daily life?

Have you had any other treatment for this issue?

If YES to the above, please briefly explain treatment and outcomes.

When did these challenges begin and what was going on in your life at the time?

We all have significant events in our lives that contribute to how we feel about ourselves, our abilities and what we deserve in life. What are the most significant events that you have experienced?

What beliefs (if any) did you form about yourself or the world as s result of these experiences?

Complete the following sentence as it relates to your business aspirations: "It would be really nice to have ________ but I can't because________".

Where do you feel these emotions physically in your body (if at all)?

Are you consciously aware of any benefits of having these challenges and if so what are the benefits? (Even when we engage in behaviours or hold beliefs that we know aren't serving us, our subconscious has a positive intent i.e. to keep us safe or avoid pain etc).

How will your life improve when these challenges are resolved? What will you start doing and what will you stop doing?

How do you want it to feel? Please be as descriptive as possible?