Self-Care Plan Intake Form
Share your preferences and habits to help us create a practical self-care plan tailored to you.
Full Name
*
First Name
Last Name
Preferred Contact Method
Email
Phone
No Contact Needed
Describe your current self-care habits
*
What are your top self-care goals?
*
Which self-care activities do you enjoy or want to try?
*
Physical activities (e.g., walking, yoga)
Creative hobbies (e.g., art, music)
Mindfulness/meditation
Social connection
Rest and relaxation
Other
How much time can you dedicate to self-care each week?
*
Please Select
Less than 1 hour
1-3 hours
4-7 hours
More than 7 hours
What barriers make self-care difficult for you?
*
Time constraints
Lack of motivation
Not sure where to start
Limited resources
Other
How motivated do you feel to improve your self-care?
*
Not motivated
1
2
3
4
5
6
7
8
9
Very motivated
10
1 is Not motivated, 10 is Very motivated
Who or what supports your self-care efforts?
Are there specific times of day you prefer for self-care?
Morning
Afternoon
Evening
No preference
Anything else you'd like to share about your self-care needs?
Submit
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