Section 01

About You

The basics, so I know who I'm preparing for.

First Name *

Last Name

Email Address *

Phone Number

Age

Location

Section 02

Your Health History

The fuller picture — diagnoses, what you've tried, and what's still unexplained.

In your own words, what's been going on? *

Not the clinical version — the real one. How long, how it affects your daily life, what it's costing you.

Do you have any current or past diagnoses?

Include physical, hormonal, and mental health — formal or suspected.

Are you currently taking any medications or supplements?

Have you had testing done — and what did it show? *

Yes — everything came back normal despite how I feel

Yes — some things were borderline or flagged

Yes — something was found but treatment hasn't made much difference

No recent testing

What have you already tried?

Practitioners, protocols, diets, supplements, programs. What helped, what didn't, what you've given up on.

Section 03

Lifestyle & Environment

Your daily environment shapes your biology in ways most people haven't been told about. This helps me see what might be adding to your load.

Daily Foundations

How would you describe your current diet? *

Mostly whole foods — I eat well but still feel terrible

Mixed — I try but it varies day to day

Highly restricted — I've eliminated a lot trying to feel better

I use food to manage emotions or stress

I don't think about it much — but I feel depleted

Any dietary restrictions, intolerances, or specific choices?

How would you rate your average daily energy? *

1 = completely depleted · 10 = vibrant and sustained

1

2

3

4

5

6

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10

1 · Depleted10 · Vibrant

How much intentional movement do you currently get? *

Very little — mostly sedentary

Occasional — once or twice a week

Regular — 3–4 times a week

Daily — consistent part of my life

Possibly too much — I find it hard to rest

Environment

Are you aware of any environmental exposures that may be affecting your health?

Select all that apply.

High plastic use / exposure

Conventional cleaning products

Conventional beauty products

Unfiltered tap water

Possible mould exposure

Not sure / haven't considered this

Section 04

The Deeper Layer

The questions most practitioners don't ask — and the practical details to make sure our call is useful from the first minute.

Have you ever explored subconscious or mindset work before? *

No — this would be new territory for me

Yes — therapy or counselling

Yes — mindset work or coaching

Yes — somatic or body-based therapy

Yes — I've done PSYCH-K® before

Are there emotional experiences or patterns you believe may be connected to how you feel physically?

Share only what feels relevant and comfortable. This isn't about having the right answer — it's about the fuller picture.

What does feeling truly well look like for you? *

Be specific. The life, not just the body.

What's brought you to seeking support right now?

Practical

Have you invested in health, coaching, or personal development support before? *

Yes — I've made significant investments in this area

Yes — some, but not a lot

No — this would be my first time

Investment comfort — what feels realistic right now? *

Helps me understand what to discuss on our call. No commitment required.

Under $500 / month

$500 – $1,000 / month

$1,000+ / month, or I prefer a lump sum program

Not sure yet — happy to discuss on the call

Your availability for sessions *

Select all that apply.

Weekday mornings

Weekday afternoons

Weekday evenings

Weekends

Is there anything else you'd like me to know before we speak?

Before We Speak