Clarity Call

Personalized Health Plan and Intake Form

I’m excited that we will be working together. Nutrition Warriors programs are not just about your physical well-being, it is also about you as a whole person: your values, goals, work, balance, fulfillment, and life purpose. Through the coaching process, we will work together to improve your ability to make positive changes to enhance your quality of life. Through exploring your internal motivators and desires we hope to attain a consistent commitment to action so you are able to move forward in a healthier direction. This proactive working relationship will accelerate your progress by providing greater focus and awareness so you are more inclined to make decisions and direct your choices to those that serve your goals and higher interests

 Your initial appointment is meant to jump-start our relationship It is only 15 minutes long. It is designed to see how we will work together, which will help me gain an understanding of who you are, what you wish for in your life, and how I can help you reach your health goals.

Please complete this intake forms and then you will be taken to my appointment calendar to schedule your 15 min. call. Again I look forward to our time together and will assist in any way I can to help you achieve your optimal health and well-being goals.

For questions 3-11 below, please take a moment to consider where you are currently and where you would like to be. For each, briefly note the reasons you chose your number. Rate 1 to 10for your current state (On a scale of 1 (low) - 10 (high) and then for each write desiredImprovements, changes or enhancements that you could make to make this area a “10” for you? ALSO BEFORE STARTING THE FORM: see below for further explanation of each area for questions 3-11.

Name *
Date *



Further Definitions

(This is to just help clarify your understanding of the terms on the current and desired states form.)

Mindful Awareness:

How much to you run on ‘automatic pilot’ and tend to ‘tune out’ of what’s going on around you? Practicing mindfulness means to pay more careful attention in a particular way. When we are mindful, we are aware of what’s going on outside and inside our own skin. All of our senses are alive and active and we know what is happening in this, the present moment. We allow ourselves to become more deeply and completely aware of what it is we are sensing.

Movement, Exercise and Rest:

Most adults should do 30 minutes of exercise, 5 days per week. To break this down further it’s suggested a minimum of 2 ½ hours a week of moderate-intensity aerobic activity (i.e. brisk walking, dancing, gardening, etc.) or 1 ¼ hours of vigorous aerobic activity (i.e. jogging, aerobic dancing, jumping rope, etc.) in episodes of at least 10 minutes, and preferably spread throughout the week. There should also be some muscle strengthening activities (pushups, weight bearing exercises, yoga, etc.)


Developing a healthy and balanced nutritional program is a cornerstone for attaining optimal health. Traditional American diets contain excessive amounts of processed foods which contribute to the development of disease and impede the healing process. Do you take the time to find nutritious foods and cook at home?

Physical Environment:

The spaces we inhabit have a major impact on how we feel, physically and emotionally. Consider: The climate, urban/country, your view, your home (clean, uncluttered, comfortable, temperature good, plants, music, lighting, décor, use of healthier alternatives for cleaning products).

Relationships and Communication:

There is a positive correlation between positive social relationships and good health. Do you get along well with your ‘inner circle’ of family and friends without them adding additional stress to your life?


Spirituality is at the core of your being; it is a central component of how you experience life and see the world. Spirituality frequently comes from our own experience of deep connection, meaning and purpose. This can provide a source of healing strength in the face of adversity, illness suffering or death.

Personal and Professional Development:

Some people have careers or daily activities (motherhood, volunteer work, creative endeavors, reading, etc.) that resonate with their purpose and values in life, while others work in jobs that have high demands with little personal or professional rewards. Sometimes there is a lack of balance across personal and professional aspects of their lives. Activities that connect us with energy, interest, satisfaction, and sheer pleasure enhance our sense of contentment and joy and ultimately to our health. These can be ‘doing’ activities or ‘being’ activities (watching the stars, watching the tide roll in, etc.).

Mind-Body Connection:

A growing body of evidence indicates that virtually every illness we experience is influenced, for good or bad, by our thought patterns and emotions. The more we can encourage different modes of ‘communicating’ between the mind, the brain and the body, the more we can gradually form healthier pathways for thought, behavior and health. How positively do I think about things and myself throughout the day?

Professional Care – Prevention and Intervention:

Do you integrate the healthcare you receive from your physicians with complementary approaches to support your health such as acupuncture, massage, nutrition counseling or weight loss programs, nutritional supplements, energy medicine, etc. Do you generally lead a healthy lifestyle – avoid tobacco, excessive alcohol and drugs, take medications as prescribed?

Coaching Session Prep Form

To be filled out AFTER your First Session – and before each subsequent session. You can get the most out of your 1st coaching call by preparing for it. Coaching is a client-initiated process. You will create the most value for yourself by focusing on what is important to you. Before each meeting, please respond to the following questions. Please e-mail the prep form to me at least 24 hours before each call. Then I can anticipate how best to meet your needs.

  1. What have I accomplished since our last meeting? (What were my small or large successes, wins, new perspectives or breakthroughs?)
  2. What are the biggest challenges I am facing now?
  3. What would I like to take away from our session today?
  4. What have I accomplished though I hadn’t said I would?