Intake Form for YHC
Email
First Name
Last Name
Phone Number
Do you prefer phone or email contact?
Phone
Email
Doesn't matter
Let's start by finding out where you are at. Check all that apply. Be honest with yourself:
I'm tired
I'm overwhelmed
I don't feed myself as well as I should
I don't meditate enough, though I think I should
I'm heavy
I don't sleep well
My day doesn't have any rhythm to it
My body doesn't move with ease
I want... Please check all that apply:
To take better care of myself
To eat healthier
Restful sleep
More energy
A deeper connection to food
To understand what my body is really made of
A more consistent meditation practice
To take better care of my skin
To move my body gracefully, pain free
Daily rhythm
More time
To let go of outdated/bad habits
How would you rate your overall energy?
Poor
Fair
Good
Excellent
How would you rate your overall sleep patterns?
Poor
Fair
Good
Excellent
Describe the breakthroughs you want to experience? Seriously - take a minute and put pen to paper.
On a scale of 1-10 where 1 is stress free and 10 is unbearable, what is your level of stress at this time?
What is your biggest source of stress or overwhelm that this time?
How IMPORTANT is change to you right now? Rate this on a scale from 1, not that important to 5, it's my main goal
How CONFIDENT are you about making these changes? Rate this on a scale from 1, not that confident to 5, "I GOT THIS!"
Are you willing to prioritize the time it takes for your growth process? Please describe on detail what that looks like in action.
What 3 things are keeping you from your best self? :
My goals aren't anchored the habits to reach them.
My peers don't have the same goals or habits.
I haven't invested in the right support.
I haven't been coached by someone who has reached the goals I want.
I haven't made health evolution into a fun process or game.
I don't know how to use my time wisely.
Have you worked with a coach before?
Yes
No
If yes, please describe what the coach and the program was like.
How would you quantify your desire to feel better? For instance, if you are spending $200 in prescriptions for joint pain and tenderness, maybe $200 a month would be it so you can get off your prescriptions.
Are you ready to invest in your growth process financially? What is this WORTH
Yes, I AM ALL IN, just need to know what it costs.
Yes, but will take hard work and redistributing funds
No, I am not so sure I can invest right now
What are the best days and times to reach you? Include what time zone you are in!
What quarter do you want to start?
Jan 2025
Mar 2025
June 2025
Sept 2025
Submit