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Intake Assessment

This is where it starts to get real.

Before We Meet

This form isn't a quiz and there are no right answers. It's just a way for me to understand where you are before we sit down together — so we don't waste time on small talk and can get straight to what matters.
Be honest. Be messy. Don't edit yourself.
I'll review everything before our session so I can show up prepared — and so you can walk in already feeling a little more seen.

Before We Meet — ICU-1111

Before our first session, I want to know a little about where you are right now. This isn't a test and there are no wrong answers. Just be honest — that's the only thing that works here.

01 The Basics

First Name *

Last Name *

Date of Birth *

Gender

Relationship Status

Email Address *

Phone Number

Occupation / Role *

How did you find me?

02 Where You Are Right Now

Rate each area of your life from 0–10 (10 being perfect). Then tell me where you want to be — and what that would feel like.

Health & Fitness

Your body is the vehicle for everything else

Now (0–10)

Goal (0–10)

What would reaching your goal feel like?

Spirituality / Faith

Your connection to something greater than yourself

Now (0–10)

Goal (0–10)

What would reaching your goal feel like?

Personal Growth & Skills

How much you're evolving and expanding

Now (0–10)

Goal (0–10)

What would reaching your goal feel like?

Intellectual Life

How alive and curious your mind feels

Now (0–10)

Goal (0–10)

What would reaching your goal feel like?

Creative Expression

How freely you express who you are

Now (0–10)

Goal (0–10)

What would reaching your goal feel like?

Career

How purposeful and fulfilled you feel in your work

Now (0–10)

Goal (0–10)

What would reaching your goal feel like?

Finances

How secure and in control you feel about money

Now (0–10)

Goal (0–10)

What would reaching your goal feel like?

Romantic Relationship

The depth and safety of your closest bond

Now (0–10)

Goal (0–10)

What would reaching your goal feel like?

Family

Your connection to your origin circle

Now (0–10)

Goal (0–10)

What would reaching your goal feel like?

Friendships

The quality and reciprocity of your chosen people

Now (0–10)

Goal (0–10)

What would reaching your goal feel like?

Community Life

How connected and contributive you feel in the world

Now (0–10)

Goal (0–10)

What would reaching your goal feel like?

Adventure & Fun

How much joy, play and aliveness you let in

Now (0–10)

Goal (0–10)

What would reaching your goal feel like?

Home & Environment

The spaces that hold and reflect who you are

Now (0–10)

Goal (0–10)

What would reaching your goal feel like?

03 What Brought You Here

What are you here to work on? * (check all that apply)

Building confidence & self-worth Figuring out life direction Breaking people-pleasing patterns Dealing with stress or burnout Relationship issues Dealing with loss or grief Healing from trauma Managing anxiety or intrusive thoughts Career clarity Developing healthier habits Decision making Developing independence

What are you currently struggling with? (check all that apply)

Depression Anxiety / Panic attacks Low self-esteem or confidence Intrusive thoughts Chronic guilt or shame Difficulty relaxing Commitment issues People-pleasing Burnout Loneliness Relationship conflict Memory issues Sexual issues Fears & phobias

04 A Little More

What do you wish people would see, notice, or understand about you?

How do you like to receive feedback or feel appreciated? *

Privately — Tell me directly, no public fanfare. Just honesty. Publicly — Acknowledge me and make it feel like a moment. Service — Show up and take something off my plate. Something tangible — A resource, a tool, something I can actually use. Progress recognition — Notice how far I've come and say it out loud. Status / Elevation — Treat me like my efforts matter. Promote me, elevate me.

That's it. You did the thing.
I'll review this before we meet so we can hit the ground running.