Clarity Session Intake Form

Do you want to create healthy habits, but don’t know where to start? Are you confused & anxious about the tsunami of information available?

Basic Information

Name *
Date
Address
Email *
Phone
Age
Height
Weight now
Weight 1 year ago
Place of Birth
Relationship Status
Children
Pets
Occupation
Hours of work per week
How did you hear about me?

What would you like to talk about today?

Please list your 3 main health concerns
Why do you want help now to address your health concerns?
What will happen if you chose NOT to address your health concern?
Other concerns
At what age in your life did you feel best? Why?
How do you feel about your age today?

Where do you want to go from here?

What would you most like to improve in your life?
Why is this improvement important to you?
Why now?
What does your ideal day/week look like?
What makes you happy?

Challenges

What has been your experience in setting goals and accomplishing them
Why do you think you need a coach
Anything else you'd like to say

Verification

Please enter any two digits *Example: 12
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I help people who are anxious or confused about food, fitness and aging,
to take the next best step so that they really enjoy a healthy life at any age.