Intake Form - Focused You

Welcome, and thank you for being here.

This quick form will help me understand what you want to focus on during our time together. There’s no right or wrong answer, just share what feels true for you right now. It should only take a few minutes.

Everything you share is confidential and helps me support you in the best way. Let’s get started.

Full Name

First Name

Last Name

Email

Location (City / Country)

Date of Birth

MM

DD

YYYY

Your Goal

What is the main goal or habit you want to focus on in this program?

Why is this goal important to you right now?

Your Current Situation

On a scale of 0–5, how consistent do you feel with this goal or habit right now?

What feels like the biggest challenge in reaching this goal?

What usually helps you stay on track when you want to make a change?

Is there anything else you’d like me to know before we begin?

I understand that this program offers health coaching and is not a substitute for medical advice, diagnosis, or treatment. I take full responsibility for my own health decisions and any changes I choose to make.

I consent to share my information for the purpose of receiving support. I know everything I share will remain confidential.