Kinesiology Intake Form

Kinesiology Intake Form
Name*
First NameLast Name
Address*
Street Address
Street Address Line 2
CityState / Province
Postal / Zip CodeCountry
Phone Number
Please enter a valid phone number.
E-mail*
example@example.com
Date of Birth*
MonthDayYear
What do you do for work and why?
What are your personal goals?
What are your professional goals?
What is your motivation in life?
What changes would you like to make in your life right now?
What are you willing to do to achieve your goals?
What do you feel are the biggest benefits to making changes now as opposed to later?
What finally made you decide that now was the time to make a change in your life?
What upsets/ triggers you?
What brings you joy?
What are you current issues? (Mental / Emotional / Spiritual etc.
Medical history (injuries | accidents | surgeries | medication etc.)
Are you currently seeing any healthcare professionals?
How are you sleeping? (How many hours, quality etc.)
Have you undertaken any personal development workshops, coaching or seminars before, if so what would've made them more impactful?
What are your looking to get out of our sessions?
Please read the list and tick any that you are currently feeling or have felt over the last 3 months*
CriticisedOverwhelmedApprehensiveUncertaintyAgitatedParanoidIntolerantMuddledGuiltyOverworkedAggravatedParalysedDepressedRejectedEasily IrritatedPersecutedHelplessAnxiousHopelessUneasySadDepressedGrievingAbusedFearfulUnable to GrieveDistressImpatientAngryWorriedOutragedSleeplessNervousRestlessIntimidatedNONE
Please give further details in relation to any areas ticked above or ANYTHING else you feel I should be aware of.
Please take a moment to contemplate and complete the following.*
Zero Low Moderate High
My family stress is
My relationship stress is
My work stress is
My financial stress is
My health stress is
Please take a moment to consider how much time you have for each of the following.*
Zero Minimal Moderate High
'ME'
Exercise
Relationship (s)
Meditation
Social
Hobbies
I want to subcribe to the Intelligentle Insights Newsletter. No spam! Just quality reading.*
YesNo
How did you hear about me?
Should be Empty:

	Zero	Low	Moderate	High
My family stress is
My relationship stress is
My work stress is
My financial stress is
My health stress is

	Zero	Minimal	Moderate	High
'ME'
Exercise
Relationship (s)
Meditation
Social
Hobbies