Client Needs Assessment Form

Name *

Email *

Phone *

Age *

What is your biggest challenge when it comes to your relationship with food and/or your body right now? *

Have you tried any specific diets or weight loss programs in the past? (Yes / No) *

Question 3. What are the top 1-2 health or wellness goals you would like to achieve in the next 3-6 months? *

On a scale of 1-10, how would you rate your understanding of intuitive eating (1 = no understanding, 10 = I feel confident about it)? *

Are there any specific symptoms or concerns you'd like help with? (Check all that apply) *

Other (please specify): *

What type of support are you looking for? (Check all that apply)