Laying the Foundation for Your Health & Well-Being
The most effective wellness strategy begins with understanding you.

This intake is designed to give me a whole-person view of your health, lifestyle, current priorities, strengths, challenges, and daily life. We’ll look at areas such as sleep, energy, stress, nourishment, movement, habits, mindset, and overall well-being so we can begin to see the patterns and connections that may be influencing how you feel.

Please answer as openly as you feel comfortable. There are no right or wrong answers, and you do not need to have everything figured out before we meet. Your responses will help us use our time together more effectively and create a conversation that is relevant, personalized, and focused on what will be most helpful for you right now.

Your responses are confidential and will provide an important foundation for our Initial Wellness Strategy Session.

Svasta Whole-Person Wellness Assessment

Before continuing with the intake, please complete the Svasta Whole-Person Wellness Assessment using the link below. The assessment provides a simple snapshot of how you currently experience several important areas of your health and well-being. It can help us recognize areas of strength, identify where you would like greater support, and see the bigger picture as we begin our work together.

After completing the assessment, please download and save your results as a PDF. You will want to keep a copy for your records, and it will allow us to revisit your starting point and recognize your progress over time.
Once completed, enter your scores in the corresponding fields below and continue with the remainder of the intake.

Once completed, please continue with the reflection questions below.
Svasta Wheel of Health: Your Sleep Quality (1-10)*
Svasta Wheel of Health: Your Energy & Vitality (1-10)*
Svasta Wheel of Health: Your Weight & Metabolism (1-10)*
Svasta Wheel of Health: Your Stress Resilience (1-10)*
Svasta Wheel of Health: Your Mental Clarity & Focus (1-10)*
Svasta Wheel of Health: Your Emotional Wellbeing (1-10)*
Svasta Wheel of Health: Your Physical Fitness (1-10)*
Svasta Wheel of Health: Your Joints (inflammation, pain) (1-10)*
What areas stood out to you the most and why?*
What areas bring you the greatest sense of well-being? *
What areas pose the greatest challenge?*
What are the top 3 health and wellness goals that feel most important to you right now?*
What does a typical day look like for you? Include details about your morning and evening routines, eating patterns, movement, and stress levels.*
How would you describe your daily energy levels? Do you feel consistently energized, experience afternoon crashes, or struggle with fatigue throughout the day?*
How do you currently feel about your eating habits? Do you feel nourished, restricted, or confused about what to eat?*
Do you experience bloating, digestive discomfort, or food sensitivities? If so, when do they occur?*
Are you currently experiencing symptoms of perimenopause or menopause? If so, which of the following are affecting you the most*
Have you tried any specific approaches (e.g., HRT, supplements, lifestyle changes) to manage these symptoms? If so, what has or hasn’t worked?*
How often do you take time for yourself, and what does self-care look like for you?*
How do you currently manage stress? What stress-reducing strategies have worked (or not worked) for you?
Describe your sleep quality. Do you fall asleep easily? Stay asleep? Wake up feeling rested? Or struggle getting deep, restorative sleep consistently?*
Who do you want to become in this phase of life?*
What does the healthiest, strongest, and most vibrant version of you look and feel like?*
How will you know that you've arrived at your ideal health?*
What would you like to achieve through our work together that would make you feel the process is a huge success?*
What would you like from your coach during your sessions: 1= not important; 10 = extremely important:
Gaining clarity of issues or challenges*
Understanding what is important/what motivates me*
Exploring and understanding what is holding me back*
Actionable steps to overcoming challenges and obstacles*
Gaining insight into my strengths, capabilities, and potential*
Providing encouragement and support*
Helping me to define my goals*
Helping to identify action and next steps*
Challenging me with thought provoking questions*
Providing honest and direct feedback*
Helping me be accountable for my goals*
What would you like your coach to do if you struggle with your goals?*
How will you know when you are receiving value from the coaching process?*
What approaches motivate you?*
What approaches demotivate you?*
Do you have any apprehension or preconceived ideas about coaching?*
How do you typically respond to being challenged? *
How do you feel about being pushed outside of your comfort zone?*
How much do you value comfort (1-10): *
How much do you value growth (1-10): *
What kind of accountability works best for you? (Check all that apply)*
Have you worked with a coach or wellness practitioner before? If so, what did you like or dislike about the experience*
On a scale of 1-10, how ready do you feel to commit to making changes to improve your health and well-being?*
What have been your biggest roadblocks to reaching your health and wellness goals in the past? What tends to get in the way the most?*
What is the most effective way that I can help and support you?*
What else would you like to share about your health, lifestyle, or goals that will help me support you better?*
Thank you for taking the time to reflect on these questions. I look forward to reviewing your responses and working together to create a personalized plan for your health and well-being!