Name * First Name Last Name Email * Phone (###) ### #### Gender Gender Female Male Other Prefer Not to Say What are your specific mental health goals? * What are your specific physical health goals? * Why are you wanting to make lifestyle changes at this time? * What healthy habits have you tried in the past that have worked for you? * What have you done in the past that hasn’t worked for you? * Please share with me any past or current health conditions or procedures you have had. * Tell me about your exercise frequency/duration and regimen, if any: * What are some of your typical meals and snacks? * How much water and non-caffeinated drinks (if not water, specify) do you drink per day, on average? * Do you consume alcohol? Yes No If so, how many drinks per week? Do you smoke tobacco? Yes No If so, how many cigarettes/other per week? Do you have any digestive issues/problems? If so, please elaborate. * How many hours do you sleep, on average? How would you describe the quality of your sleep? * How are you hoping that I can be of help to you? * Please feel free to share any other relevant information or anything you feel would benefit our work together. Thank you for taking the time to fill out the form. I will be in contact soon!
