Full Name
*
First Name
Last Name
Date of Birth
MM
DD
YYYY
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
(###)
###
####
Preferred method of communication for lifestyle requests
Preferred payment method
Profession / Occupation
Hours worked in week
Number of kids (if applicable) and ages
Number of pets and types (if applicable)
Marital Status
Single
Married
Divorced
Separated
Widowed
Domestic Partnership
If in relationship, on a scale of 1 to 10, how strong is your relationship currently?
In what areas of your life could you use help managing (select all that apply)
List 3-5 things that take up the most time in your day-to-day life?
If you could take away 3-5 things in your day, week, month what would they be?
List 3-5 things you just wish someone else would do for you?
In what areas of your life do you feel the most overwhelmed?
If you could pick 3 things that would make your life happier/easier, what would they be?
What do you want the most in your life? List it all. The sky is the limit. Anything is possible.
What areas of your life do you want to change?
What do you need more of in your life?
What makes you happy, smile, laugh and why?
Do you make time for self care practices? Yes/No If so, what types:
Do you make time for fitness practices? Yes/No If so, what types:
Interests & Hobbies (select all that apply)
Other Hobbies (not listed above)
On a scale of 1 to 10 (10 being the best), how would you rate your physical health?
On a scare of 1 to 10 (10 being the best), how would you rate your mental health?
What are your top 3 favourite restaurants?
What are your top 3 places to travel?
What can I do to make your life easier?
Economy, Business/First Class or Private?
MAC or PC?
If you could only keep 5 possessions, what would they be?
How would your friends describe you?
