Consultation Form

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Personal Information:

1 First Name

2 Last Name

3 Age

4 DOB

5 Height

6 Weight

7 Place of Birth (City & State)

8 Current Address (City & State)

9 Is there anything else you would like to share in this section that wasn’t mentioned? Remember all information is confidential.

Family Life:

1 Are you the only child in your family?

Yes No

If your answer is no, how many siblings do you have? Are they brothers or sisters?

Are you the oldest, youngest, or middle child?

Oldest Youngest Middle

2 Did you grow up with both parents in the household?

Yes No

If your answer is no, which parent were you raised by, your mother or father?

Were you raised in an upper-, middle-, or lower-class family?

Upper Middle Lower

3 Did you experience any trauma in your childhood? If so, please explain in depth.

Yes No

If so, please explain in depth.

4 Were you physically, sexually, emotionally, or mentally abused as a child?

Yes No

If so, by whom?

5 Did you experience abandonment as a child?

Yes No

If so, by whom?

6 Did you get along with your siblings during your childhood?

Yes No

As a child, which sibling were you close to?

7 Were you a latchkey kid growing up?

Yes No

8 Did you relocate a lot as a child?

Yes No

9 Was your dad, mom, or both parent’s alcoholics when you were younger?

Dad Mom Both Neither

10 Is your dad, mom, or both parents still alcoholics?

Dad Mom Both Neither

11 Were you raised in a loving family as a child?

Yes No

12 Did you hear the words, “I love you” often as a child?

Yes No

13 Did you receive hugs, and affection from your parents as a child?

Yes No

14 Were you close to your dad, mom, or both parents growing up?

Dad Mom Both None

15 Were you close to your siblings growing up?

Yes No

16 Did you experience family dinners as a child?

Yes No

17 Did you take family vacations as a child?

Yes No

18 Did you grow up in a strong, supportive, family environment?

Yes No

19 Do you have any children?

Yes No

If so, how many?

Do you have a close relationship with your children?

Yes No

20 Is there anything else you would like to share in this section that wasn’t mentioned? Remember all information is confidential.

Personal Life:

1 Are you an introvert, extrovert, or both?

2 What drives you to get out of bed every day?

3 What are your favorite hobbies?

4 What makes you happy?

5 What things irritate you or make you upset?

6 Do you have insecurities?

Yes No

If so, what are they?

7 Do you think you are pretty or handsome?

Yes No

8 Do you love yourself?

Yes No

9 Are you insensitive to other people’s feelings?

Yes No Sometimes

10 Is it easy for you to show empathy?

Yes No Sometimes

11 Is it easy for you to be apathetic?

Yes No Sometimes

12 Do you struggle with forgiveness?

Yes No

13 What are you passionate about?

14 Describe your perfect day in detail.

15 Do you find that you get jealous easily?

Yes No

16 Do you compare yourself to others?

Yes No

17 List 5 qualities that you love about yourself.

18 List 5 qualities that you want to improve or strengthen within yourself.

19 Is there anything else you would like to share in this section that wasn’t mentioned? Remember all information is confidential.

Education:

1 What is your highest level of education?

2 Did you make friends easily in school?

Yes No

3 Were you popular in school?

Yes No

4 In school were you: shy, outgoing, reserved?

Shy Outgoing Reserved

5 Were you bullied in school?

Yes No

6 Did you bully students in school?

Yes No

7 What subject(s) were easy to learn in school and what subject(s) did you struggle with?

8 What was your favorite subject in school?

9 What was your least favorite subject in school?

10 Did you have a favorite teacher or instructor in school/college?

Yes No

If so, why were they your favorite?

11 Do you value the education you have received?

Yes No

12 In what ways do you continue to educate yourself in your career and/or daily life?

13 Is there anything else you would like to share in this section that wasn’t mentioned? Remember all information is confidential.

Nutrition:

1 Did you grow up drinking well water, faucet water, bottled water, or filtered water?

2 Did you have home cooked meals as a child, or did you eat fast food and at restaurants growing up?

3 How many meals a day did you eat as a child?

4 Did you pack a lunch to school, or did you eat the school’s breakfast and lunch?

Packed a lunch Ate school’s breakfast and lunch

5 Did you drink a lot of sodas, juices, or kool-aid growing up?

Yes No

6 Did you eat junk food and candy as a child?

Yes No

7 Do you currently drink alcohol?

Yes No

What types of alcoholic drinks do you consume?

Are you an alcoholic?

Yes No

Do you use drinking alcohol to numb yourself from your traumas, pains, and problems?

Yes No

If Yes, Please Explain

Why do you drink alcohol?

How old were you when you had your first alcoholic beverage?

8 Do you currently eat fast food and at restaurants?

Yes No

Where do you normally eat at?

9 Do you cook your meals at home?

Yes No

10 Do you currently consume sugary foods or desserts?

Yes No

What do you eat?

11 Do you incorporate whole foods in your nutrition?

Yes No Sometimes

12 Do you eat fruits and vegetables?

Yes No Sometimes

What are your favorite fruits?

What are your favorite vegetables?

13 Do you purchase organic produce?

Yes No

If so, what produce do you buy organic?

14 Do you purchase organic groceries?

Yes No

If so, what groceries in particular do you buy organic?

15 Do you follow any particular diet or nutritional lifestyle?

Yes No

Which nutritional lifestyle do you currently follow

Please type the nutritional lifestyle that you follow

16 Do you eat to live or live to eat?

Eat to Live Live to Eat

17 What is your relationship with food?

18 Are you an emotional eater?

Yes No

19 Do you struggle with cravings?

Yes No

If so, what foods do you crave?

20 Do you have any food allergies or intolerances?

Yes No Unsure

If so, please list all food allergies and intolerances in detail

21 How many ounces, cups or gallons of water do you drink a day?

22 What type/brand of water do you mostly drink?

23 Are you a coffee drinker?

Yes No

How many cups of coffee per day do you drink?

1 2 3 4+

24 Do you consume energy drinks, soda/pop, or other caffeinated beverages?

Yes No

If so, please list them in detail.

25 Please list in detail what a typical day of eating looks like.

26 Is there anything else you would like to share in this section that wasn’t mentioned? Remember all information is confidential.

Fitness:

1 Do you currently workout?

Yes No

How many minutes/hours a day do you work out?

30 min. or less 1-2 hours 3-4 hours 5+

How many days per week do you train?

Where do you train?

2 Do you have a regime, routine, or program that you follow?

Yes No

Please describe your regime, routine, or program in detail

3 Is exercising a part of your lifestyle?

Yes No

Does exercising make you feel good?

Do you notice that you have better days when you exercise?

4 Do you find yourself overtraining your body?

Yes No

If so, what body part(s) do you overtrain and why do you overtrain them?

5 Do you think that you can be obsessive with your training at times?

Yes No

If so, please explain

6 Do you enjoy working out alone or with others?

7 When you are not training, what wellness practices do you have in place throughout the day?

8 Are you an athlete?

Yes No

Please Choose

Please specify

9 Do you have any fitness or wellness goals?

Yes No

If so, please explain in detail.

10 If you have never been physically active, would you be open to start a regime, routine, or program?

Yes No

11 Did you grow playing sports?

Yes No

Please list all sports that you played

12 Were you physically active as a child?

Yes No

13 Are you sedentary at your job or career or do you move around?

14 Do you walk during your breaks at work?

Yes No

15 Do you currently have any injuries?

Yes No

If so, please explain in detail.

16 Have you ever had any surgeries?

Yes No

If so, please explain in detail.

17 Is there anything else you would like to share in this section that wasn’t mentioned? Remember all information is confidential.

Lifestyle :

1 Do you consider yourself to be a healthy person?

Yes No

2 Is having a healthy mind, body, and soul important to you?

Yes No

3 What is your stress level like?

4 How well are you sleeping?

6 How do you feel when you wake up?

7 Do you have PTSD (Post Traumatic Stress Disorder)?

Yes No

8 Are you currently on any medications?

Yes No

If so, please list medications and for how long you’ve been taking them.

9 Are you using drugs either recreationally or for medical reasons?

Yes No

If so, please list all drugs that you are taking and for how long you’ve been using them.

10 Do you struggle with any eating disorders?

Yes No

If so, please explain in detail.

11 Do you struggle with showing your emotions to others?

Yes No

If so, Please explain in detail.

12 Do you struggle with controlling your emotions?

13 Do you enjoy being alone, around others, or both?

Alone Around Others Both

14 Do you easily get drained by people?

Yes No

15 Do you feel lonely?

Yes No

If so, how often and why?

16 Do you struggle with depression?

Yes No

If so, how often and what makes you depressed?

17 Do you get angry easily?

Yes No

If so, what in particular makes you angry?

18 What (if anything) are you unwilling to give up?

19 Is there anything else you would like to share in this section that wasn’t mentioned? Remember all information is confidential.

Relationships & Romance :

1 What is your current relationship status?

Single Married Widowed

2 Have you ever been married?

Yes No

3 Have you ever been divorced?

Yes No

4 Have you ever been cheated on?

Yes No

More than once?

Yes No

By Whom?

5 Have you ever cheated?

Yes No

If so, how many times?

Did you cheat on the same person, with different partners, or both?

6 Have you ever been in love?

Yes No

7 Do you use sex as a form feeling loved or wanted?

Yes No

8 Do you feel like you have ever been loved by any of your partners?

Yes No

9 What is your love language in relationships?

10 Are you romantic?

Yes No

What ways do you show your romantic side?

11 Do you have issues with trust in relationships?

Yes No

12 Do your partners have trouble trusting you?

Yes No

13 Do you communicate well in relationships?

Yes No

14 Do your partners communicate well with you?

Yes No

15 Do you struggle with abandonment in relationships?

Yes No

16 Are you secretive in your relationships?

Yes No

17 Have you ever felt like you were putting more effort into your relationship than your partner?

Yes No

18 Is there passion in your relationship?

Yes No

19 Do you find that you are bored or just coexisting in your relationship?

Yes No

20 Do you believe in unconditional love?

Yes No

21 Have you ever been in an abusive relationship?

Yes No

If so, please describe the situation as detailed as you can.

22 Have you ever been the abuser in any of your relationships?

Yes No

23 Is your partner your best friend?

Yes No

24 Does your partner consider you their best friend?

Yes No

25 What areas of your relationship do you think need improvement?

26 Are you happy in your current relationship?

Yes No

27 Do you think your partner is happy with you?

Yes No

28 Is there anything else you would like to share in this section that wasn’t mentioned? Remember all information is confidential.

Media & Technology:

2 How many minutes/hours a day do you talk and text on your phone?

3 How many hours a day do you spend on your computer or laptop?

4 Do you have any social media accounts?

Yes No

If so, what social media platforms are you on?

6 What other technology devices do you have?

7 Is time spent on social media affecting your family, romantic relationships, friendships, or business relationships, or job/career?

Yes No

If so, please explain in detail.

8 Do you use social media as an escape from reality or from your personal problems?

Yes No

If so, please explain in detail.

9 Do you use your phone, laptop, or other electronic devices like a kindle to read?

Yes No

If so, what do you use?

10 Do you like to read hardcover books?

Yes No

11 Do you prefer reading a hardcover book or using an electronic device to read?

Hardcover Book Electronic Device

14 What is your favorite novel?

15 What are you currently reading?

16 Is what you listen to, watch, or read mostly positive, upbeat, and inspirational, or violent, negative, and aggressive?

Positive, Upbeat, and Inspirational Violent, Negative, and Aggressive

Please explain in detail why you choose to listen to, watch, or read violent, negative, and aggressive content.

17 Have you ever catfished anyone?

Yes No

if so, Please explain in detail.

18 Are you on any dating apps?

Yes No

If so, what dating apps are you on?

19 Do you find yourself pretending to be someone else on social media, dating apps, or any other platform?

Yes No

20 Do you play video games?

Yes No

Are the video games you play violent and use vulgar language?

Yes No

21 List all of the video games you play

22 Do you listen to music?

Yes No

23 What are your favorite genres?

24 What are your favorite artists or bands?

25 How does the music you listen to make you feel?

26 Do you listen to music that is upbeat and positive, or do you listen to music that is vulgar, aggressive, and negative?

Upbeat and Positive Vulgar, Aggressive, and Negative

27 How does hearing profanity in music make you feel?

28 What time of day do you find yourself listening to music?

29 Do you watch porn?

Yes No

How many hours a day do you watch porn?

How many hours a week do you watch porn?

Does porn affect your sex life with your partner or significant other?

Yes No

If so, please explain in detail.

Do you have an addiction to porn, or have you ever been told you have an addiction to porn?

Yes No

If so, please explain in detail.

30 Is there anything else you would like to share in this section that wasn’t mentioned? Remember all information is confidential.

Spirituality:

1 Are you spiritual, religious, or neither?

Spiritual Religious Neither

What is your denomination (Christian, Catholic, Muslim, Jewish, Buddhist, Atheist, etc.)?

2 Did you grow up in a spiritual or religious family?

Yes No

3 Do you believe in God?

Yes No

4 Do you believe in practices like prayer, meditation, unconditional love, forgiveness, etc.?

Yes No

If so, list the practices you believe in.

5 Do you believe you have a purpose in life?

Yes No

If so, what do you believe your purpose is?

6 Have you ever felt a void in your life?

Yes No

Do you currently feel a void in your life?

Yes No

7 Do you practice gratitude?

Yes No

8 Do you journal?

Yes No

9 Do you read anything motivational or uplifting on a regular basis?

Yes No

10 When was the last time you read a book?

11 Do you have faith?

Yes No

If so, what do you have faith in?

12 How do you want to be remembered before you take your last breath in your lifetime?

13 What is your favorite quote or motto?

14 Do you go to church?

Yes No

15 What legacy do you want to leave behind for the next generation?

16 Is there anything else you would like to share in this section that wasn’t mentioned? Remember all information is confidential.

Career:

1 Do you believe you have a job or a career?

Job, Career Neither

Please explain

2 What is your job or career?

3 How long have you been in your job or career?

4 Do you enjoy your job or career?

Yes No

5 How many hours a week do you work?

6 Do you make time for yourself when you are not working?

Yes No

7 Do you make time for your family and friends when you are not working?

Yes No

8 Are you exhausted once you get home from your job or career?

Yes No

9 Do you currently feel fulfilled in your job or career?

Yes No

10 What would be your ideal career that would make you happy to have?

11 Is there anything else you would like to share in this section that wasn’t mentioned? Remember all information is confidential.

Finance:

1 Do you struggle with saving money?

Yes No

Do you struggle with spending money?

Yes No

2 What is your mentality towards money?

3 Do you pay your bills and other expenses on time?

Yes No

4 Are you currently in debt?

Yes No

5 Have you ever been in debt?

Yes No

6 Have you ever filed for bankruptcy?

Yes No

7 Do you have good credit?

Yes No

8 Do you equate money to happiness?

Yes No

9 Is money always a topic in your relationship?

Yes No

10 Are you living paycheck to paycheck?

Yes No

11 Is there anything else you would like to share in this section that wasn’t mentioned? Remember all information is confidential.

Please Fill Out The Form Below:

Personal Information:

Family Life:

Personal Life:

Education:

Nutrition:

Fitness:

Lifestyle :

Relationships & Romance :

Media & Technology:

Spirituality:

Career:

Finance:

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