Coaching Intake Form

Life & Wellness Coaching

Getting to Know You

Please do your best to answer the following questions in advance if possible. Alternatively, we can review these questions during your appointment.

Your Information

Full Name *

Email Address *

Phone (optional)

Light & Environment

Approximately how many hours in a day do you get to have natural daylight?

How much tech / screen time do you average per day?

What type of lighting do you have at home? (LEDs, incandescent, salt lamp, etc.)

Hormones

Have you taken birth control pills or hormone replacement therapy at some point?

Hydration

How much water do you drink daily and what type of filtration?

Vitamins & Supplements

What vitamins or supplements do you currently take? You can also text pictures to 437-608-2978.

Medications

What medications are you taking or have taken in the past? You can also text pictures to 437-608-2978.

Health History

Do you get sick yearly? How many times a year?

Difficulties with weight management?

Are you dealing with physical pain from joints and muscles?

Have brain fog or difficulty focusing? Mood swings?

Diet & Nutrition

Can you describe what 1–2 days of eating looks like for you?

Are you on a plant-based diet? Keto, Carnivore, Vegetarian?

Are you constantly hungry or snacking?

Sleep

How is your sleep? What time do you go to bed and wake up? If your sleep gets interrupted, what time? Do you feel energized in the morning or have a hard time getting up?

Detox & Caffeine

Have you ever done any detoxing or juicing? What type?

Do you drink caffeine throughout the day?

Your responses are sent directly to Suzanne and kept confidential.

For questions, feel free to call or text 437-608-2978

Appreciated,
Suzanne