Maria Scrimenti Intake Form
Hi there, thank you for your interest in working with me! 

Please take your time filling out this form. Not only will it help me decipher if/how I can guide and support you, it will also help you create clarity as you process what you're currently going through. The more specific, thorough, thoughtful, and honest your responses are, the better.

To be clear, this form does not obligate you to work with me, but I sincerely appreciate you considering having me as your coach. Once you submit the form, I will reach out to you for next steps. 

I look forward to reading your responses and hope to have the privilege of empowering you to step into your most free and confident self! If you have any questions, feel free to email me at maria@mariascrimenti.com.

Warmly,

Maria 


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Email *
First & last name + pronouns *
Phone number
Occupation
What is going well for you right now, in your life in general? *
How do you currently feel about your body?  *
What are your biggest challenges in your relationship with food? *
What have you done before to try to fix this? *
How is a poor relationship with food and your body interfering with your quality of life? What are you missing out on? What are you afraid might happen if you don't fix this?  *
How confident do you feel that you can fix this by yourself? *
Not at all confident. I need help or nothing will change.
Extremely confident. I can fix this without any professional support.
What are your top 3 goals for coaching? 
(Think about what you want your relationships with food & your body to look like 6 months from now.)
 *
How ready are you to start making changes to improve your relationships to food & your body?  *
Have you ever invested in coaching or counseling before? *
How did you find me? *
Anything else you want me to know?
A copy of your responses will be emailed to the address you provided.
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