I’m SO excited to support you in unleashing your full potential, co-creating with the magnificent energetic forces of The Universe that are literally encoded all around you.

Welcome!

I’m SO excited to support you in unleashing your full potential, co-creating with the magnificent energetic forces of The Universe that are literally encoded all around you.

Intake Form

Full Name

Full Mailing Address

Email Address

Phone Number

Age

Date of Birth

Occupation

Current & Previous Medications

Nutritional Supplements

List vaccines received (full childhood schedule fulfilled, flu, etc.) If you've received any vaccines in the past year, please provide approximate dates.

Diagnosed medical conditions

Illnesses, injuries & surgeries with approximate dates

Allergies

Dental history including any fillings, crowns, root canals, implants & types of materials used

Percentage of organic Food you eat

How frequently you eat out

How much water (in ounces) you drink daily

If you consume coffee, soda or sweetened beverages, what & how much/often (i.e., 2 cups of coffee per day)

Please describe your sleep habits. Do you maintain a consistent sleeping and waking schedule where you go to sleep and wake up at approximately the same time from day to day? How many hours do you sleep?

Do you have trouble falling or staying asleep? If yes, please provide details.

Do you have trouble waking up in the morning?

Work schedule (i.e., Monday to Friday 9am-5pm)

Exercise schedule - what and how often

Please share some details about your relationships. Do you have a significant other? Do you have children? Do you have close friends? Do you have contact with other family members, i.e. parents, siblings, relatives, etc.?

On a scale of 0-10 with 0 being unsatisfied and 10 being very satisfied, how happy are you with your FAMILY LIFE?

On a scale of 0-10 with 0 being unsatisfied and 10 being very satisfied, how happy are you with your ROMANTIC LIFE?

On a scale of 0-10 with 0 being unsatisfied and 10 being very satisfied, how happy are you with your WORK LIFE?

On a scale of 0-10 with 0 being unsatisfied and 10 being very satisfied, how happy are you with your PLEASURE & LEISURE?

On a scale of 0-10 with 0 being unsatisfied and 10 being very satisfied, how happy are you with your FINANCES?

On a scale of 0-10 with 0 being unsatisfied and 10 being very satisfied, how happy are you with your HEALTH?

On a scale of 0-10 with 0 being unsatisfied and 10 being very satisfied, how happy are you with your VISION FOR YOUR FUTURE?

On a scale of 0-10 with 0 being unsatisfied and 10 being very satisfied, how happy are you with your RELATIONSHIP WITH TIME?

On a scale of 0-10 with 0 being unsatisfied and 10 being very satisfied, how happy are you with your SLEEP & ENERGY?

On a scale of 0-10 with 0 being unsatisfied and 10 being very satisfied, how happy are you with your RELATIONSHIP WITH YOURSELF (self love)?

Please share any concerns you have about investing time, energy and resources into developing your full potential. I encourage and welcome radical honesty.