REFORM - Intake Form
Hi there! I'm so excited to get started together! Congratulations on taking the leap 🎉

Please set yourself up in a comfortable space and take your time to fill out the following questions.

These responses will help me get a more holistic picture of you and your personal growth, empowerment + goals, and will also serve as a gift to yourself as you reflect and vision.

If a question doesn't apply or stumps you, no worries! Do your best and move on!

Remember, our work is set on a foundation of trust, honesty, non-judgment, vulnerability, and courage. There may be fear, discomfort, and resistance. It's all part of it!

Welcome to REFORM:
A holistic approach to your body + wellness. Level up your work in the studio with personalized, integrative lifestyle support for the body, mind, and spirit!


I look forward to working alongside you in your wellness journey!

Much love,  Stacie

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What is your full name (@time of birth), birthdate, time of birth and location of birth? *
What are the top 3-5 outcomes that would feel most like a WIN for you in our time together? *
What do you believe is holding you back from achieving that today?
Has there been a time in your life when you felt like this desired outcome has been achieved or you’ve been where you want to be now previously? What life experiences occurred (internally or externally) to shift you “off track”?
What do you believe to be HARD or DIFFICULT about achieving your wellness goals?  What are the current behaviors, habits, or routines that are NOT supporting you to achieve your wellness goals?
What are your current behaviors, habits, or routines that are working well for you?
What do you know about how the mind and body work together currently?
Clear selection
What does a typical day look like for you? (Including wake & sleep times, where there is space or not in your schedule, work schedule, travel, kids, pets, etc.)
What are your 5 highest personal values (rated most to least important)?
Creating a picture of an ideal version of you - if I could have you zoom out and see yourself through a frame, what are you doing, what do you look like, how do you feel?
If you had an extra 10 hours per day where you felt fully energized and capable of doing anything you desired, what would you be spending your time doing?
What did you learn growing up and throughout life about being healthy?  What does that mean to you?  
How would your life change if you were in radiant, optimal health?  What greater impact could this have on your overall experience of life?
Current stress level rating (1-10)? (1 = not at all, 10 = most stressed in my life)
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Current quality of sleep  rating (1-10)?  (1 = not good, 10 = I wake up like a dream)
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How many hours of sleep do you typically get per night?
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How often are you cooking, eating out, etc?
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Do you have any dietary restrictions, allergies or preferences?
What kinds of foods do you LOVE the most? Dislike the most?
Which of the following substances do you use to help you feel more energized and “ON” throughout the day?
How do you most love to move your body and manage your stress? What doesn’t feel good?
Is there anything else you would like me to know?
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