Is this right for you?

Thank you for your interest in working with me. This short pre-screening questionnaire is an essential first step in our journey together. It helps me understand where you’re currently at, what you’re looking for, and whether my approach is the right fit for you.

I work with women who are ready to move away from dieting and build a more sustainable, supportive relationship with food. If you’re seeking strict meal plans, calorie tracking, or quick fixes, my approach may not be the right fit for you.

Intake Questionnaire

First name

Last name

Phone

Birthday

Day

Month

Year

Section 1: Nutrition Goals & Expectations

What are your hoping to achieve from working together?

What would success look like for you?

Section 2: Mindset

How do you currently feel about your relationship with food?

Are you open to a non-diet, long-term approach to nutrition?

Section 3: Your Readiness for Change

On a scale of 1–10, how ready do you feel to make changes?

What has stopped you from achieving your goals in the past?

Section 4: Health History

Have you been diagnosed with any medical conditions or are you currently experiencing any ongoing health concerns?

Section 5: Your Capacity & Commitment

Are you able to commit to implementing changes and attending follow-up sessions?

Section 6: Consent & Privacy

Your privacy is important to us. All information shared in this form is kept strictly confidential and used solely for the purpose of your nutritional assessment.

I consent to the collection and processing of my health data for nutritional counseling purposes.

Thank you for sharing your story.

After submitting your questionnaire, I will review your responses. If we’re a good fit, you’ll receive a link to book your consultation.