Private Consulting Intake Questionnaire

Focus Questions

Thank you for taking the time to complete this questionnaire.

There are no right or wrong answers, and you don’t need to have everything figured out before we meet. This is simply an opportunity for me to begin understanding your experience, what’s bringing you here, and where you’d like our work together to take you.

Please answer as openly as feels comfortable. You are welcome to share as much or as little as you wish. Everything you provide will be treated with the utmost care, respect and confidentiality.

Name

Today's Date

What time zone are you in?

Where did you hear about me?

What's brought you here today? Take your time. This is a space to share whatever feels most relevant to your reasons for seeking support at this point in your life.

What would you say is your biggest challenge at the moment?

On an average day, which three emotions do you experience most often?

When you feel emotionally triggered, what's your usual response? For example: fight, flight, freeze, fawn, or something else entirely.

If you could name one pattern that seems to repeat throughout your life, what would it be?

What's one thing you know is holding you back that, despite your best efforts, you've not yet been able to change?

What feels like it's already working well in your life? What strengths, qualities, relationships or habits feel solid and supportive?

If you could wake up tomorrow and everything was exactly as you wanted it to be, what would be different?

In your own view, what's been getting in the way of creating the changes you most want?

At this stage in your life, do you feel more committed to creating meaningful change, or to staying with what's familiar? There is no judgement here—only honesty.

Our work together may involve gently exploring uncomfortable truths in service of helping you become more fully yourself. If that becomes part of the process, do you feel ready for that?

Is there anything else you'd like me to know before we meet? There may be something important that hasn't been covered above. If it feels helpful, you're welcome to share it here. Everything you tell me will be held with care, respect and complete confidentiality.