Full Name
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First Name
Last Name
Email
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Location (City / Country)
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Which program are you joining?
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Focused You
How did you find me?
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I’m a past client
Referred by a friend or colleague
I know Mariana personally
Found you on social media (Instagram, Facebook, etc.)
Through another practitioner or coach
Someone shared your content with me
Other
Do you have children?
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Yes
No
Do you have pets?
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Yes
No
What does a typical day look like for you?
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What are the main health concerns, symptoms or challenges you’re currently experiencing (physical, emotional, hormonal, etc.)?
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Any other concerns or goals you'd like to work on?
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Have you been diagnosed with any health conditions?
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Yes
No
How is your digestion?
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Regular & comfortable
Constipation
Diarrhea
Gas or bloating
Other
How is your sleep?
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Deep & restful
Light or interrupted
Difficulty falling asleep
Wake during the night
Do you have a menstrual cycle?
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Yes, regular
Yes, irregular
In perimenopause
In menopause
No
Do you take any medications or supplements?
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Yes
No
Are you currently working with any healthcare providers, therapists, or coaches?
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Yes
No
How would you describe your relationship with food right now?
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Do you currently follow any specific way of eating?
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Do you have any food cravings (e.g., sugar, salty foods, coffee)?
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What kind of physical activity do you currently do (if any)? How often?
What helps you feel grounded or emotionally well?
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What kind of support helps you most?
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Structure & clarity
Accountability
Emotional exploration
A safe space to reflect
Other
What’s one thing you wish could feel different in your daily life right now?
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What’s one thing you’d love to shift or improve in the next 2–3 months?
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Is there anything else you’d like to share before we begin?
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