Coaching Intake · Confidential

Self-Sabotage Intake
Everything is confidential.

Take your time with this. The depth of your answers directly shapes what's possible in the work we do together. Nothing here is judged — only used to help you.

Section 01

Contact Information

First Name *

Last Name *

Email *

Alternate Email *

Phone Number *

Date of Birth *

Street Address *

City

State / Province

Postal / Zip Code

Time Zone

Time Zone of Place of Birth

Height *

Weight *

Patient Gender *

Preferred Gender

Marital Status *

Previous Marital History

Number of Children

Ages and First Names of Children

Current Occupation

Past Occupations

Skype Name

Facebook Profile URL

Instagram Profile URL

Next of Kin — Name

Next of Kin — Phone

Next of Kin — Email

Section 02

Why You're Here

What is the primary reason you've made contact, and in what area(s) do you need improvement? *

Are there any particular or pressing issues you'd like addressed during the coaching session?

Tell me your story. Unload a bit about what's eating at you — about life in general, yourself, or your historical/current situation. I got time. Let it out. Everything is confidential.

Section 03

Medical History

List all medications taken over the last 10 years — full names please

How many vaccines have you taken over the last 20 years?

Have you ever taken an antidepressant? If so, which ones and over what length of time?

Please list all surgeries over your entire lifetime — including elective and cosmetic

Do you have any diagnosed diseases?

How many times have you been in the medical system over the last 5 years, and for what issues?

Have you invested in any alternative health practitioners — chiropractors, energy healers, hypnotherapists, etc.?

Have you ever visited a Chinese medical doctor? If so, what was the diagnosis — which organ system(s) needed support?

Section 04

Body & Symptoms

Please list the aches and pains you have over your entire body — where do you hurt?

Do you use any over-the-counter medicines — painkillers, allergy medicines, etc.? If so, which ones and how frequently?

Have you done any cleanses or fasting? If so, which ones and when?

Do you have any allergies — food or otherwise? Please list.

Do you have acne or disrupted/discolored skin?

Do you have itchy skin or itchy areas of your body?

Do you wear corrective glasses or contacts?

Do you frequently feel cold?

What is the state of your fingernails, toenails, and hair? Describe — brittle, ridged, thinning, etc.

Do you have any mercury fillings (grey/black)? If so, how many — and do you remember the ages when you got them?

Do you have any composite (white) fillings? Do you remember the ages when you got them?

Do you have any root canals? If so, how many and when were they done?

What toothpaste do you use?

Does your toothpaste contain fluoride or carrageenan?

Is the water in your area fluoridated?

Do you have any new or emerging marks on your skin or skin tags?

Section 05

Exercise & Movement

Do you exercise on a regular basis?

Describe your full weekly exercise routine in detail

Home equipment you DO use

Home equipment you own but NO LONGER use

How many diet programs have you tried over your lifetime?

How many different gyms or health studios have you been a member of over the last 20 years?

Do you have any diet or healthy cookbooks in the house?

What is the date in your history where you were the heaviest you've been?

Section 06

EMF & Technology Exposure

This section matters more than most people expect. Be honest and precise — these patterns are clinically significant.

Do you use a wireless laptop on your lap?

Do you hold your cell phone to your ear or in your pocket?

Do you keep your cell phone within 3 feet of you for most of the day?

Do you wear a Fitbit, iWatch, or similar wearable?

Do you use wireless headphones or other wireless devices?

Do you have WiFi at home?

Do you have WiFi at your business or workplace?

Do you have a Smart TV (wireless)?

Do you work in an industry with heavy WiFi exposure?

Do you live in an apartment complex with many WiFi signals?

Do you have any baby monitors in the house?

Do you have a WiFi measuring device?

How many hours per day are you within 5 feet of a computer, phone, laptop, or wireless router?

Do you have a smart meter on your home?

Is your bedroom within 20 feet of a smart meter or meter bank?

Do you have solar panels on or near your home?

Are there cell towers, power lines, or antenna arrays within visible distance of your home?

Do you use a grounding mat, grounding sheet, or other grounding product?

Do you have a smart thermostat, smart doorbell, or other smart home devices?

Do you have a hybrid or electric vehicle?

Do you live in a high-rise building or above the 3rd floor?

Describe your bedroom EMF environment as best you can — what devices are in the room, what's on the other side of the walls, distance to router, etc.

Section 07

Sleep

What time are you going to bed (last 6 weeks)?

What time are you getting up (last 6 weeks)?

Is your sleep interrupted at generally the same time nightly? If so, what time?

Do you feel tired during the day at generally the same time? If so, what time?

If you work night shift, please describe your schedule

Do you watch TV or any screen before going to bed?

If yes — how long before sleep do you watch a screen?

What do you typically watch before bed?

Do you wear blue light blocking glasses before sunrise or after sundown?

Name 5 TV series you've watched over the last 5 years

Name the last 5 movies you've watched on Netflix, in a theater, etc.

Section 08

Diet & Substances

Be precise and accurate. These numbers matter clinically. Nothing is judged here.

Describe your caffeine intake in exact amounts per week — coffee, energy drinks, teas, pre-workout, chocolate, etc.

Do you use any nicotine products? Include cigarettes, vaping/e-cigarettes, nicotine patches, nicotine gum, chewing tobacco, nicotine pouches (Zyn, On!, Velo, etc.), or therapeutic nicotine protocols. Note type, brand, frequency, and dose.

Do you drink alcohol? If so, how many ounces / beers / glasses of wine per day — be accurate.

Do you currently use narcotics? If so, what and how much per day — be accurate.

If you no longer use narcotics, alcohol, cigarettes, or coffee — what ages did you use them and in what quantities?

4-Day Diet Log — everything you eat and drink (including gum, medications, vaping, chewing tobacco). Note if food is organic, biodynamic, humanely raised, or conventional.

How much water do you drink daily and what brand or source?

Please name all personal care products you use daily and the brands

Do you use a microwave to heat or defrost food?

How long does it take to eat your meals, and do you eat them with family, alone, sitting down, in a car, or standing?

Have you adopted any healthy habits over the last 5 years? Describe exactly what they were.

Do you do any active relaxation — meditation, breathwork, walking in nature, etc.?

How many vacations do you take per year — alone or with a partner?

Section 09

Relationships & Life Context

Are you currently getting what you need emotionally or sexually inside your current relationship?

Did anything occur in your life that you consider traumatic? Please describe if you wish.

Did anything occur in your life that you hold guilt or shame about? Please describe if you wish.

Have you ever filed for bankruptcy? If so, how many times and in what amount?

Other than a home mortgage, do you have credit card debt over $5,000?

If male — were you circumcised?

If female — were you exposed to any genital cutting?

Name all clubs, associations, or groups you belong to or affiliate with

Do you attend religious services currently?

Did you attend religious services or Sunday school in your first 7 years of life? If so, with what frequency?

Name all the schools you attended in chronological order — note if they were public or religious

Do you play music in your car and if so, what stations or genres?

Do you find yourself too busy and working too much at times?

Do you have any piercings or tattoos? Describe how many, what they are, which side of the body, and location.

Have you ever cut yourself or hurt yourself purposely?

Name your 3 best friends — their estimated weights, occupations, and diseases or addictions

Do you live in a lower, middle class, or upper class neighborhood?

Did any of your parents wear a crucifix or do you wear one?

Section 10

Family Background — Parents

If you don't have a mother or father, use the person who filled that role in your life.

Did you move around often as a child? How many houses did you live in, in which cities, and for how long?

Were those areas wealthy, middle class, or poverty-stricken?

Please list everyone in your immediate family with ages and first names

Did your mother or father drink alcohol, smoke, drink coffee, eat junk/fast food, or use narcotics weekly when you were a child?

Was there physical hitting or sexual abuse toward the children in the family home?

Did either of your parents or siblings have a criminal record when you were a child?

Were either of your parents overweight? Please list by name/initial and approximate weight.

Did either of your parents follow a structured weekly exercise routine?

What was/is the sexual orientation of both parents?

Mother's occupation during your childhood — all sources of income/jobs for as long as you remember up to present

Father's occupation during your childhood — all sources of income/jobs for as long as you remember up to present

Did your mother or father take any medications?

What was the general routine in the family home? Describe a typical day for each parent.

Were you raised by one or both parents?

If a parent passed away or your parents divorced when you were a child — when did it happen, and how did you feel?

Is there anything hurtful or very impactful that either of your parents said or did to you during your childhood? What sticks out the most?

If you had to use one word or phrase to describe the dominant emotional "cloud" in your family home growing up — what would it be?

Section 11

Family Background — Siblings

How many siblings do you have? List them by first name and age — place yourself in the order.

Current marital status of each sibling

Weight and height of each sibling

Any diseases each sibling has been diagnosed with

Are you aware of any medications your siblings take — and for what?

Siblings: occupations, sexual orientations, any addictions, use of alcohol / coffee / cigarettes / junk food / narcotics weekly, fast food habits, adoption status

Section 12

Personal Growth & Healing

Read questions 1–4 first, but do not answer them yet. Complete the rest of this section first, then come back to answer questions 1–4. You'll understand why when you get there.

Read now — answer last

1. What is your dream? If you had $150 million in your bank account right now, what does your daily and yearly routine look like? What do you want to accomplish before you pass away?

2. What do you stand for? What are your core values that you'll never negotiate, regardless of what's offered in return?

3. What are you willing to change to improve your life?

4. Fill in the blanks: I am X, Y and Z... creating X, Y and Z. My vision is X, Y and Z.

What you absolutely DON'T want — 4 declarations for each category below

Health — I don't want...

Wealth — I don't want...

Relationships — I don't want...

Positive Self-Talk — I don't want...

Where are you encountering the most resistance or active self-sabotage — health, wealth, relationships, or positive self-talk?

Write down 4 words or phrases about your mother that describe something that drives you a little crazy or something you can't really deal with

Write down 4 words or phrases about your father that describe something that drives you a little crazy or something you can't really deal with

Ask a best friend or ex-partner to describe 4 things about you that drive them a little crazy. Do you see any overlap with your lists above?

Limiting beliefs — Wealth

Limiting beliefs — Health

Limiting beliefs — Relationships

Limiting beliefs — Positive Self-Talk

What are the perceived benefits of keeping those limiting beliefs? What does your subconscious get to keep by staying stuck?

Now go back up and answer questions 1–4.

You've done the work. Now write from your heart and soul. It's time to start shaping the life you want by telling your mind exactly what you want it to manufacture.

1. What is your dream? (with $150M in the bank — what does your daily and yearly life look like?)

2. What do you stand for? Your non-negotiable core values.

3. What are you willing to change to improve your life?

4. Fill in the blanks — I am... I am creating... My vision is...

Dream sensory detail — 4 statements per answer

Wealth dream

What is your wealth dream?

What does it sound like?

What does it taste like?

What does it feel like?

Health dream

What is your health dream?

What does it sound like?

What does it taste like?

What does it feel like?

Relationship dream

What is your relationship dream?

What does it sound like?

What does it taste like?

What does it feel like?

Positive self-talk dream

What is your positive self-talk dream?

What does it sound like?

What does it taste like?

What does it feel like?

You've done the work.

Everything you've written here is confidential and will only be used to support the work we do together. Take a breath. You just did something most people never do.

Self-Sabotage Intake Everything is confidential.

Contact Information

Why You're Here

Medical History

Body & Symptoms

Exercise & Movement

EMF & Technology Exposure

Sleep

Diet & Substances

Relationships & Life Context

Family Background — Parents

Family Background — Siblings

Personal Growth & Healing

Self-Sabotage Intake
Everything is confidential.