Have you noticed any recurring patterns in your relationships, work, or decision-making?

Is there anything that keeps happening despite your efforts?

Have you worked with a therapist, a coach, or other practitioner before?

If yes, what was helpful? What was not?

Are you currently experiencing any of the following?

Check all that apply.

Are you currently taking any medications?

If yes, please list:

Are you currently working with a psychiatrist, therapist, or other mental health professional?

If yes, please describe your current treatment or support:

Have you ever been hospitalized for mental health reasons, or experienced suicidal ideation?

If yes, please provide brief context (When did this occur, and what support did you receive?):

How would you rate your current physical health?

Do you have any chronic health conditions or physical limitations I should be aware of?

Current movement and exercise habits:

Sleep quality:

Current stress level:

What concerns do you have about this process, if any?

This work requires looking honestly at uncomfortable patterns you may have been avoiding. Are you prepared for that level of engagement?

How did you hear about Impasse Life Recovery?

Is there anything else you would like me to know about you, your situation, or what you need from this work?

By typing your name below, I confirm that I have read and agree to the following:

• This is a coaching relationship, not therapy or medical treatment. Impasse Life Recovery does not diagnose, treat, or manage mental health or medical conditions.
• I am responsible for my own decisions and actions throughout this process.
• I may discontinue services at any time, in accordance with the terms of my service agreement.
• All information shared will be kept strictly confidential, except where disclosure is required by law.