Seeded in Curiosity | Client Intake Assessment

Section 1 of 8

About you

First name

Age

Email address

What brought you here? What made you reach out right now? (be as honest as you want)

What do you most want to feel like at the end of our 12 weeks together?

Have you worked with a coach, therapist, or wellness practitioner before?

If yes, what worked and what didn't? (optional)

Section 2 of 8

Energy and burnout

How would you describe your energy levels on a typical day?

Which of these do you recognize in yourself? (check all that apply)

Constant mental chatter that won't quiet Difficulty resting even when exhausted Dreading things you used to enjoy Feeling behind no matter how much you do Emotional flatness or numbness Irritability or short fuse Physical tension, jaw clenching, tight shoulders Relying on caffeine to start and alcohol to wind down

What does your relationship with rest look like right now? (be honest, no judgment)

Section 3 of 8

Sleep

Average hours of sleep per night

Sleep quality overall

Which sleep patterns do you experience? (check all that apply)

Trouble falling asleep Waking up in the night Racing thoughts at bedtime Waking up unrested even after 7+ hours Relying on sleep aids or melatonin Alcohol to fall asleep Phone in bed until you fall asleep Irregular sleep schedule

What does your wind-down routine look like, if you have one?

Section 4 of 8

Your body and your cycle

This section helps us understand your hormonal baseline. Everything here is private and will only be used to personalize your program. Skip anything you are not comfortable with.

Do you currently have a menstrual cycle?

Which of these do you experience around your cycle? (check all that apply)

Significant mood shifts Energy crashes at specific times Intense cravings Brain fog or difficulty focusing Bloating or digestive changes Sleep disruption Anxiety that feels physical I don't track or notice patterns

How would you describe your relationship with your body right now?

How much water do you drink daily?

Describe your relationship with food and eating right now (no judgment, just honesty)

Section 5 of 8

Movement and exercise

How often do you move your body intentionally each week?

How does exercise feel in your body right now?

Do you ever push through workouts when your body is clearly asking for rest?

Section 6 of 8

Mindset and behavioral patterns

Is there a pattern you keep trying to change but can't seem to crack? (describe it honestly)

What does your inner voice sound like when you make a mistake or fall off track?

Section 7 of 8

What is in your system

This section is not about judgment. It is about seeing the full picture. Everything you share here stays between us and helps me build a program that actually works for your body. I am not a doctor and will never tell you to change or stop any medication. What I may do is help you bring informed questions to your care team.

Are you currently taking any prescription medications? (you do not need to list names, just categories help)

Antidepressants (SSRIs, SNRIs) Anti-anxiety medication Stimulants (Adderall, Vyvanse, Ritalin) Hormonal birth control Thyroid medication Sleep medication Other prescription medication None currently

Are you currently taking any supplements? (check all that apply)

How much caffeine do you consume daily?

Do you use nicotine in any form?

How often do you drink alcohol?

Is there anything about what you consume (food, substances, medications) that you feel affects your wellbeing but you haven't been able to address yet? (optional, entirely your choice to share)

Section 8 of 8

Your goals and readiness

What is the one thing you most want to change in the next 12 weeks?

What has stopped you from making this change before?

Is there anything else you want me to know before we begin? Anything you are nervous about, hoping for, or want me to understand about you?

Welcome. Let's see the
whole picture.

About you

Energy and burnout

Sleep

Your body and your cycle

Movement and exercise

Mindset and behavioral patterns

What is in your system

Your goals and readiness

Thank you. Your intake is in.

Welcome. Let's see thewhole picture.

About you

Energy and burnout

Sleep

Your body and your cycle

Movement and exercise

Mindset and behavioral patterns

What is in your system

Your goals and readiness

Thank you. Your intake is in.

Welcome. Let's see the
whole picture.