Assessment Form 

Please complete the form below. Note that all information is confidential and will be treated with the utmost consideration and discretion. The more thorough and complete your answers are the sooner we can get your transformation underway!

Name _______________________________________

DOB____________                   Gender____________        

Address________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Email_______________________________________

Phone_______________________________________

Do you prefer to be contacted via phone, email, text, social media or any other form of communication?. _______________________________________

Ethnicity_________ Relationship Status __________

If partnered, for how long? _____________________

On a scale of 1-10, 1 being not at all, and 10 being as satisfied as you can imagine, how satisfied are you with the state or your relationship. _________________

How many people reside in your home? _____

Do you have children or dependents living in your home?   Y   or   N

Emergency Contact___________________________________________

(Nature or the Relationship)___________________________________

 

Education:

What is the highest level of education you have achieved?

GED                       High School         Some College                  BA/BS/BFA____        

Graduate Degree                        Doctoral Degree

Additional certifications, degrees, awards, licenses, trainings,  etc. Please list.

_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Using a 1-10 Scale (1 - Not at All and 10, Completely Satisfied) How Satisfied Are You With Your Education?

______________________________

 Please Explain

Were you  at anytime given special services or supports to help manage school work and or organization, etc.,?   Y    or     N

If Yes, Briefly Explain:

_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Employment

How old were you when you held your first job? ________

What was the first job you ever held? _________________________________

Occupation___________________________________

Company/Organization ________________________

Years in Current Position: ________

Briefly Describe Your Job

Is Your Job Physically Active or Physically Demanding Challenging ?  In What Ways?

Job Satisfaction (circle one).

Not at All Satisfied     Satisfied    Totally Satisfied    Uncertain    Other_______________.

Career Satisfaction (circle one)

Not at All Satisfied     Satisfied    Totally Satisfied    Uncertain    Other_______________.

Using a 1-10 Scale (1, Not at All and 10, As Much As I Can Imagine) How Stressful Is Your Job?

What Would You Say is the Most Stressful Part of Your Work?  

How Many Hours Each Week Do You Spend Working?  ___________

How Many Hours do You Spend In Front of a Computer at Work? At Home?

Home__________

Work__________

How Long After You Wake Up Each Morning Do You Check the Following…….?

Email__________

Text Messages ________

Social Media _______

Other_______

Using a 1-10 Scale (1 - Not at All and 10, As Much As I Can Imagine) How Stressful is Your Personal Life? __________

What Is the Main Source of Your Stress Right Now?

Income (circle one)  

Not Enough     Just Enough     Enough     More Than Enough    Way More Than Enough

Do You Currently Have Multiple Income Streams? _________

Is Money a Source of Stress or Anxiety For You?_________

If So, How Often Do You Find Yourself Worrying About Money? Please Explain.

_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

___________________________________________________________________________________

How “Successful” Would You Describe Your Family as Having Been in the Following Areas?

Mother or Maternal Figure If Applicable

Financial Success:   Not at All    Somewhat    Succesful     Very Successful     Among the 1% .

Love & Romance: Not at All    Somewhat    Succesful     Very Successful     Ideal

Friendship:            Not at All    Somewhat    Succesful     Very Successful     Ideal

Mental Health:        Not at All    Somewhat    Succesful     Very Successful     Ideal

Physical Health:      Not at All    Somewhat    Succesful     Very Successful     Ideal

Father or Paternal Figure If Applicable

Financial Success:   Not at All    Somewhat    Succesful     Very Successful     Among the 1% .

Love & Romance: Not at All    Somewhat    Succesful     Very Successful     Ideal

Friendship:            Not at All    Somewhat    Succesful     Very Successful     Ideal

Mental Health:        Not at All    Somewhat    Succesful     Very Successful     Ideal

Physical Health:      Not at All    Somewhat    Succesful     Very Successful     Ideal

Health

How would you describe the state of your overall physical health right now?  (circle one)

Extremely Healthy       Good Health      Average Health         Poor Health          Bad Health

If Below Average,  please explain___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

How would you describe the state of your overall mental health right now?  (circle one)

Extremely Healthy     Good Health     Average Health    Poor Health             Bad Health

If Below Average,  please explain _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Do you have any chronic health problems (mental or medical) or challenges? (Ex: asthma, diabetes, depression, anxiety, fibromyalgia). _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

If yes, for how long? _________________________

Have you ever been diagnosed with a mental illness?       Y       or      N

Please Explain _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Health Consciousness

How much time out in your week do you put aside especially for the following:

Exercise (ex: 4 hours) ____________________

Meal Prep________________________________

Meditation ________________________________

Spiritual Connection ________________________

Social Interaction___________________________

Family Time_______________________________

Sexual Health ______________________________

Rest _____________________________

Sleep (Hours Per Night) ___________________________

In the past year circle any of the following professionals in the field of health that you may have seen for more than a routine visit? If so why, and for how long?

Medical Doctor           Physical Therapist       Nurse Practitioner       Counselor/Therapist

Social Worker             Psychologist (PhD)      Psychiatrist (M.D)      Pharmacologist

Homeopathic DR       Functional Neurologist    (Other)___________

______________________________________________________________________________________________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

Circle from the list below those who at any time you may have worked with.

Nutritionist                             Herbalist                Acupuncturist                         Massage Therapist

Personal Trainer                     Yoga Instructor      Executive Coach                    Dance Coach

Life Coach                             Clinical Coach        Athletic Coach                       Reiki/Energy Healer

Mindfulness Coach                Priest/Rabbi/Pastor

Sponsor                                  Mentor

Voice Coach                           Sports Psychologist

(Other)___________

Have your ever developed a practice or discipline such as any of the following?

Yoga                   Pilates             Martial Arts

Meditation          Crossfit           Dance

Tai Chi                Weightlifting   Boxing

Cycling               Swimming      Trapeze/Aerial Arts

Gymnastics          Running

(Other) __________

Are There Any Other Notes About Your Lifestyle that You Would LIke to Share? Or that Would Be Helpful For Us To Know? Please explain.

How much time, if any, would you say you put in each week to ensure that your mind & body are healthy and strong? (Ex: 3 hours at the gym)

Is there a specific challenge, behavior, or area of your life that you would like to focus on specifically? Please explain.

What, if anything, do you think has interfered with you from making the change(s) that you have wanted to make up until now?

Have you ever had any type of long term meditation practice? (Over 3 months)

Do you now or have you ever found yourself relying on alcohol and drugs to feel better?

Have you ever gone long periods of time without using alcohol or drugs?

Do you feel if asked to abstain from substance use for the next 3 months you would have a problem doing so?       Y     or          N       or     I Don’t Know

Religious/ Spiritual Affiliation: ______________________________________