Intake Form — Impasse Life Recovery

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Self Development

Physical Health & Corrective Exercise

Modern Dating Coaching

Under Construction

Self Development

Physical Health & Corrective Exercise

Modern Dating Coaching

Under Construction

Folder: Offerings

Self Development

Physical Health & Corrective Exercise

Modern Dating Coaching

Under Construction

Client Intake FormStep 1 of 3

Your Impasse

History & Health

Lifestyle & Consent

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Please complete the highlighted fields before continuing.

Basic Information

Contact details

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Full Name

Age

Email Address

Phone Number

Current Occupation or Life Situation

Please enter your name and email address.

Your Impasse

What are you currently facing?

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Please describe the specific situation, patterns, or feelings that led you to seek support at this time.

I prefer not to answer this question

A response is required, or please select prefer not to answer.

What do you hope to achieve through this work?

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Try to be as specific as possible. How could your life be different?

I prefer not to answer this question

A response is required, or please select prefer not to answer.

What are the biggest obstacles to achieving the change you desire?

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Does anything specific get in the way?

I prefer not to answer this question

A response is required, or please select prefer not to answer.

Which approaches have you already tried?

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Were any of them successful, even on a temporary basis? Did any approach work better than others?

I prefer not to answer this question

A response is required, or please select prefer not to answer.

Do you feel that your situation can change?

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Yes, with the right support No, I have no control over the outcome

Please tell us more about why you feel this way:

I prefer not to answer this question

Please select an option, or prefer not to answer.

Please complete the highlighted fields before continuing.

Patterns & History

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

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Yes No

If yes, what was helpful? What was not?

Please select Yes or No.

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

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Is there anything that keeps happening despite your efforts?

I prefer not to answer this question

A response is required, or please select prefer not to answer.

Mental Health & Wellbeing

Are you currently experiencing any of the following?

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Check all that apply.

Depression or persistent low mood Anxiety or excessive worry Trauma-related symptoms ADHD or executive function challenges Relationship difficulties Substance use concerns Sleep disturbances Eating or body image concerns None of the above

Please select at least one option.

Are you currently taking any medications?

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Yes No

If yes, please list:

I prefer not to answer this question

Please select Yes or No, or prefer not to answer.

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

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Yes No

If yes, please describe your current treatment or support:

Please select Yes or No.

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

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Yes No

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

I prefer not to answer this question

Please select Yes or No, or prefer not to answer.

Please complete the highlighted fields before submitting.

Lifestyle & Physical Health

Physical health, sleep, and stress

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How would you rate your current physical health?

Excellent Good Fair Poor

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

Current movement and exercise habits:

Regular exercise (3+ times per week) Occasional exercise (1–2 times per week) Sedentary lifestyle Active through work or daily life

What kinds of exercise do you do?

High-intensity training Weight-lifting / resistance training Cardio (running, cycling, swimming) Yoga Stretching / flexibility work Sports

Sleep quality:

Generally good (7–9 hours, feel rested) Inconsistent (some good nights, some poor) Poor (difficulty falling or staying asleep, wake unrefreshed)

Current stress level:

Low Moderate High Overwhelming

Please select your physical health rating.

Readiness & Commitment

Readiness and concerns

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How ready are you to make meaningful changes? Select one:

1

2

3

4

5

6

7

8

9

10

1 = not ready10 = completely ready

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?

Yes Uncertain No

Please select your readiness rating and level of preparedness.

Physical Health Coaching

Are you looking for physical health coaching in addition to self-development coaching?

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Yes No Possibly

Sliding Scale Rates

Do you think you will need to discuss sliding scale rates?

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Sliding scale rates are available for those who qualify. If cost is a barrier to accessing services, I still encourage you to reach out, we can discuss other options.

Yes No Unsure

What is your approximate annual household income? This helps us determine eligibility.

Under $25,000 $25,000 to $40,000 $40,000 to $55,000 $55,000 to $75,000 Over $75,000 Prefer not to share

Please select an option.

Additional Information

Is there anything else you would like me to know?

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This could include your situation, what you need from this work, any medical conditions, medications, or other factors I need to be aware of before we begin.

I prefer not to answer this question

Consent & Agreement

Please read and confirm the following before submitting

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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.

Full Name (digital signature)

Date

Please check all consent boxes and type your full name.

One Last Thing

How did you hear about Impasse Life Recovery?

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Google search Social media Referral from: Other:

Thank you.

Your intake form has been received. I will be in touch within 1–2 business days to schedule your initial session.

IMPASSE LIFE RECOVERY

impasseliferecovery@gmail.com