Brain Body Life — New Client Intake Form
Share your details, your current concerns, and how you’d like to be contacted so we can arrange your Clarity Call or book your first session.
Your details
Full name
*
First Name
Last Name
Email address
*
example@example.com
Phone number
Preferred contact method
Email
Phone
Text
Your enquiry
Pathway enquiring about
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Pay-as-you-go
Resilient Reset
Signature programs
Not sure yet
Which consultation are you interested in?
Dispensary Support — 15 min, $50
Quick Start — 30 min, $150
Follow-Up Session — 45 min, $200
Complex Initial Consultation — 60–90 min, $250–$350
Complex Consultation Pathway (3-session package: Reset, Restore, Optimise) — $570
Not sure yet
Which format suits you?
Group — 4-week live online program, $390 (create your own group of 4–10 friends, save $40 each — no group yet? join the waitlist)
1-to-1 — 6 weeks including 75-min deep-dive and 5 weekly sessions, $1,590 bespoke private container
Not sure yet
Which tier are you drawn to?
Tier 1 — The Foundation, single-session health audit, $450 one-off
Tier 2 — The Breakthrough, 90-day Reset & Empower container, $1,350–$2,250 depending on monthly or bi-weekly access
Tier 3 — The Transformation, 6–12 month concierge partnership, Personalised investment
Not sure yet
What would you like to do next?
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I'm ready to book my first session
I'd like a complimentary 15-minute Clarity Call first
Not sure yet — let's talk
In your own words, what's going on for you right now?
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Your age / life stage
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Under 35
35–49
50–64
65+
A few things we should know
Current medications or supplements
Existing diagnoses we should know about
Currently pregnant or breastfeeding?
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Yes
No
N/A
The first step in getting to know you
This helps me prepare for our conversation — the rest happens when we actually talk.
What you're currently experiencing
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Gut & digestion — bloating, irregular digestion, food sensitivities
Brain, fatigue & sleep — brain fog, low energy, poor sleep, low mood or anxiety, wired-but-tired
Hormones — hot flushes, night sweats, irregular cycles, low libido
Muscles, joints & bones — joint pain, muscle loss, bone density concerns
Skin — breakouts, dryness, texture or tone changes
Heart & cardiovascular — elevated cholesterol, blood pressure concerns
Metabolic health — blood sugar swings, weight changes
Caregiving load or overwhelm — stretched thin, burnout, no time for herself
What feels most pressing right now?
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My body (physical)
My mind (mental/emotional)
Both equally
Have you explored support like this before? — naturopathy
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Yes
No
Have you explored support like this before? — coaching, NLP, or therapy
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Yes
No
Beyond our sessions, how much time can you realistically set aside each week for yourself?
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Under 30 min
30–60 min
1 hr or more
What would you like our work together to help you achieve?
*
Submit
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