Client Intake Form

This is the online form to be filled out for our 90-Minute Consultation.
Please follow the steps below:

  • Complete this Client Intake Form
  • Submit $150 secure payment via PayPal
  • Schedule 90-Minute Review Session

During our 90-Minute Review Session, I’ll gather your information in more detail.

Collecting this information will allow me to get to know your unique life and health experiences up to this point to prepare for our first health coaching session soon after.

I look forward to getting started.




  • Confidential Client Information

  • Statistics

  • History

  • Health Concerns

  • Nutritional Status

  • Intestinal Status

  • Medical Status

  • Health Hazards

  • Lifestyle History

  • Sleep History

  • For Women Only

  • Sexual History

  • Mental Health Status

  • Other

  • Forms of relaxation

  • Food

  • Other

$150 Fee For Consultation

Thank you for taking the time to fill out this form and for your payment!

I look forward to talking soon.