Client Intake and Personal History Name * First Name Last Name Email * What are the reasons (problems, challenges, circumstances) that brought you here (to do this work)? * The problems I need help with are: * On a scale of 1-10 how intensely do you experience this problem? * List what you have done so far to try to resolve this problem. Are you currently working with anyone else to resolve it? * List why or how these problems effect your life * How long has this been a problem or struggle in your life? * What specifically created this problem? * How do you feel about this problem (what emotions exist)? * Tell me about your family and childhood as it relates to this current situation (what is the relationship between your past experiences/people and your current problem)? Is there a purpose or reason for having this problem? * How will you know when this problem has totally disappeared (what will that look like or feel like)? * Are you willing to take the steps necessary in order to release the problem from your life/resolve the problem? * On a scale of 1-10 how committed are you to use your time, resources and energy toward overcoming this problem? * My biggest goals are: * Do you struggle to find balance between your fitness needs, personal needs, life tasks, social life and work? When time is tight, which is the first area you cut down on? * What do you find most challenging in life (relationships, work, money, family, etc)? * What is most challenging for you, balance or discipline? * What areas would you like to see healing/growth in? * What are some of the things that you feel limit you in growth or block you from living to your fullest ability? * What are you most grateful for in life? * Thank you!