Client Profile Form

General Information

First, I’m so thrilled you’re here and I can’t wait to meet you and get to know you better. I am honored to work with you and excited to get started. Let’s get the basics out of the way, shall we?

What is your name?

How do you like to be called?

What is your email?

For reminders and check-ins, do you prefer email or text?

If text, what is your number?

And your mailing address is?


Current Assessment

Let’s assess where you are in your life and how you are coping with your life. Feel free to share as much or as little as you would like.

Tell me about your illness as your condition affects you right now.

What is your condition costing you in terms of the full quality of your life? Be specific and consider in terms of time, productivity, home life, social life, spirituality/meaning, intimacy, movement, recreation.

What does your typical day or week look like?

What is your favorite part of your week?

What is your least favorite?

What are your biggest frustrations about your life right now?

How long has this been a struggle for you?

What area of your life needs the most upgrading?

Who else, if anyone, is affected by your illness?

Do you have any special sensitivities that would be helpful to share? (such as to aromas, or temperatures or topics)


Dreams + Hopes

 

I know dreaming and hoping can be painful. We endure so many disappointments. But let’s suspend disbelief for a moment and fantasize, shall we? Again, answer as fully or as sparely as you are comfortable with.

If I could wave a magic wand and get you the results you are after, what would those results look like?

What is a priority for you, right now?

If you could fix only one thing that could boost and help solve other difficulties, what would that one thing be?

What is your why? What is your motivation to learn and work to shift aspects of your life?

What are your best skills?

What do you most appreciate about yourself?

What area of your life are you the most proud of?

Name three specific things that would definitely be a part of your best life.

Name three specific things that would definitely not be a part to living your best life and you would eliminate if you could.

What do you feel you need the most help with in your life? Check all that apply.

breathe work
connection to nature
dealing with unexpected symptoms
emotional resilience
home environment
invisibility of illness
journaling for healing
meal preparation
meditation practice
mindset
more joy & delight
movement
navigating difficult relationships
pain management
planning for the future
self-esteem boost
self-soothing techniques
sleep quality
yoga you can do
other - please provide details


Establish Baselines

 

Let’s establish some baselines before we start.

What is the quality of your sleep? (by which I mean how you feel when you wake)
Scale 1-10 with 1 being very poor and 10 being like an Olympian.

What is the ease of which you eat healthy food?
Scale 1-10 with 1 being very hard and 10 being super easy

How would you rate your resilience?
Scale 1-10 with 1 being easily broke and 10 being fluid and bouncy

How much movement of your body do you have in your life?
Scale 1-10 with 1 being basically none and 10 being everyday without restriction

How much fun do you enjoy during a typical week?
Scale 1-10 with 1 being laughter is rare and 10 being I laugh at least once a day

How empowered do you feel in your daily life?
Scale 1-10 with 1 being a victim of everything and everyone and 10 being I’m the captain of my ship


Open-Ended Query

 

This is where you can tell me anything. Please do.

Is there anything else you’d like to share?