Weight Control Intake Form
In preparation for any work we do together, it would be helpful if you could fill out the following form. A copy will be emailed to me for my review.

Based on your form, I may have a referral or other recommendations for you, including materials for you to review before we meet.

If you feel any of your eating habits may be due to traumas related to any time of your life where you felt the fear of or actually experienced the trauma of shame, abandonment, rejection or betrayal, I highly recommend reading The Mind Body Code by Dr. Mario Martinez. Copy and paste the following link into a web browser to order the book on Amazon: https://www.amazon.com/MindBody-Code-Beliefs-Longevity-Success/dp/1622031997/ref=pd_sim_14_1?ie=UTF8&dpID=41J%2BrUGW3qL&dpSrc=sims&preST=_AC_UL160_SR107%2C160_&psc=1&refRID=PTQ3JP1SDNS4ZWNE1RJW/mymindmypick-20

You can get a good taste of the book and a really useful self help technique by listening to this Sounds True Podcast. Copy and paste the following link into a web browser: http://www.soundstrue.com/store/weeklywisdom/?page=single&category=IATE&episode=10111

There is also a book called The Body Keeps Score that can give you an idea about how our bodies are affected from a wide variety of traumas. You can listen to the audiobook version on Youtube. Just copy and paste the following link into a web browser: https://youtu.be/53RX2ESIqsM

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Which best describes you?
What is your current weight and what weight would be most healthy and ideal for you?
Your answer
Please list 3 to 5 of the most motivating reasons you can think of to live a healthier lifestyle and therefore achieve and sustain your ideal weight.
Your answer
When did you first notice you were gaining excess weight and why do you think this occurred?
Your answer
Please give a brief history of things you may have already done to help yourself get to your goal weight. Describe what you enjoyed or did not enjoy.
Your answer
How would you rate the typical amount of energy you experience on a daily basis?
I feel like a sloth
I feel like a spring lamb
Please describe your current activity habits. What, if anything, do you do for exercise and how often?
Your answer
Please describe your current diet and what kind of changes you wish to make if any. Please include the amount of vegetable servings, sweets and alcohol you typically consume on a daily or weekly basis.
Your answer
How severe have any cravings for unhealthy foods been for you?
Mild
Irresistible, I'd steal it from a baby!
Would you say you've been using certain foods for...
Have you recently or are you currently experiencing significant levels of stress? If so, why?
Your answer
What do you think are the new mindsets and habits we would need to enforce in order to help you naturally, consistently and more easily achieve a healthier weight?
I.e. If you've been an emotional eater, what would you like to do instead of eating?
Your answer
One reason many people feel fatigued and eat more than necessary is from not drinking enough water. Typically, it's best to take your current weight in pounds, divide by 2 and drink that many ounces of water a day. (Ex. I weigh 112 lbs. so I stay well hydrated by drinking at least 56 oz. of water a day). How many 8 oz. cups of water do you tend to drink a day?
Your answer
Do you have any medical conditions or are you on any medications that have made it a challenge for you to reduce your weight?
Your answer
When is the last time you had a thorough physical examination? Also, are you currently under the care of a Medical Doctor or Naturopathic Doctor? Please give their name if so.
Your answer
Do you use recreational drugs? If so, how often?
Your answer
When you start to lose weight or when you achieve your ideal healthy weight, would there be any challenges you would have to be ready to face? (Handling compliments or comments from others, attention from men or feeling safe, etc.)
Your answer
What are you willing to invest in this process in order to get your desired results? (I ask this question so that I can let you know, after reviewing your form, whether I believe we will be able to accomplish effective results for you within your given budget.)
We do our best to get any breakthroughs you need and train your mind into ways of thinking and feeling about things that will best support your ideal healthier weight. To further ingrain and protect new thought and behavior patterns, you may also find it helpful to listen to a recording of your session or do reading, exercises, meditations, and adjunct therapies I recommend. Is that something you would be willing to do to make the most out of our work together?
Your answer
Please list any concerns, questions or things you would like me to know should we have the pleasure of working together.
Your answer
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