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Freedom Intake Form
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* Indicates required question
Name
*
Your answer
Age
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Your answer
Occupation
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Your answer
What is your level of stress? (1 minimal stress, 10 extreme stress)
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1
2
3
4
5
6
7
8
9
10
Do you have any injuries or health conditions (both past and/or present)?
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Your answer
Describe your weekly physical activity.
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Your answer
Describe your diet.
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Your answer
Describe your spiritual or religious or self-care practice.
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Your answer
Are you aware of any limiting beliefs or recurring self-deprecating thoughts?
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Your answer
What habits would you like to break?
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Your answer
What is your relationship with time?
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Your answer
Why do you want to participate in this program? What do you hope to release/gain?
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Your answer
What are you willing to let go of so you can have what you've always wanted?
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Your answer
How committed are you to transforming your life for the better? 1-10
*
Your answer
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