Your Story,

Your Health

welcome — let’s get to know you.

Before we begin our work together, this form is a way for me to understand you — your story, your health, your goals, and what wholeness looks like for you. There are no wrong answers. Everything you share is held with care and kept confidential.

The more I know, the more I can tailor our sessions to meet you where you are. Whether you're navigating fatigue, stress, gut issues, hormonal shifts, or simply seeking more balance and vibrancy, this is your space to be honest and real.

What to Expect:

This form takes about 10–15 minutes to complete.
Please answer what you can — it’s okay if you’re not sure about everything.
Your responses help shape a personalized wellness plan that fits your life and values.

Once I receive your form, I’ll email you to schedule your free 50-minute consultation. If it feels like a good fit, I’ll recommend a 3-, 6-, or 9-month program — and we’ll get started on transforming your health.

Name

First Name

Last Name

Phone

(###)

###

####

Occupation

What are your health and wellness goals?

Why are they important to you?

What's the most important thing you'd like to share about your health story?

Is there anything from your childhood pertaining to your health you’d like to share?

Do you have any medical diagnoses or conditions?

What foods did you grow up eating?

How would you describe your past relationship or history with food?

Describe your current relationship with food.

Do you experience any digestive issues (bloating, gas, constipation, etc.)?

How many hours of sleep do you get per night? Do you wake feeling rested?

How often and what types of movement do you enjoy?

How would you rate your stress levels on a scale of 1–10?

How would you rate your overall energy throughout the day? When do you feel your best during the day? When do you feel your lowest?

Is there anything else you'd like me to know about your health, history, or goals?

Your Story,

Your Health

welcome — let’s get to know you.

What to Expect:

This is a powerful first step toward feeling more like yourself.

I’m so glad you’re here.