Wellness Questionnaire

Please submit your responses before our time together.

If there are questions that do not apply, answer with N/A.

Name

First Name

Last Name

Birth Date (day/mo/year), Time & Location

T-Shirt Size

Occupation

Emergency Contact: Name, Number & Relation

Moon Cycle

If applicable, please indicate first date of your last period, length of bleed and general length of your cycle.

Pregnancy

+If applicable and you feel comfortable sharing, please indicate number of pregnancies, births & what kind such as vaginal or c-section, miscarriages and/or terminations. +If currently, please indicate how many weeks. +If TTC, please indicate.

Household

Please list the names and ages of the individuals you live with.

Allergies

Dietary Restrictions

Medications

If yes, please indicate.

Diagnoses

Please indicate for medical and/or psychiatric or psychological.

Alcohol/Cannabis/Tobacco/Substance Use

If yes, please indicate which one and frequency of use.

Have you in the past or are you now attending professional counseling/psychotherapy?

Trauma History

If yes, please share anything you wish for me to know.

How do you support and nourish yourself (physical, emotional, mental and spiritual practices)?

What do you feel the most challenged with? Where might you feel stuck?

What do you know it is high time to let go of?

What are you calling in for yourself and/or what is your highest dream?

Where do you wish to see yourself in 6 months and/or how do you wish to feel?

Are you ready and willing to commit to practices that will help empower your full wellness?

How can I support you and what are your intentions for our time together?