Client Intake Form

What are your goals & expectations while working with me?

What are you typical breakfast, lunch & dinners?

Check all of the factors that apply to your eating habits and current lifestyle:
How many alcoholic drinks do you currently have per week?
Please check all current symptoms or those present during the past the 6 months

On average, about how many hours of sleep do you get per night?

Is there anything else about either your history or your current lifestyle that you feel is important to mention?

© 2019 by Lindsay Cribbs