Assessment Form - Self Care Routine

Thank you for taking a moment to complete this form, it helps me best prepare your personalized 10-minute self-care audio routine.

Confidentiality Note
I commit to keeping your responses confidential and secure. I understand that many of these questions are personal and fully respect if you choose not to share information that is prompted in the questions below.

Assessment Form:

Name

First Name

Last Name

Email

What's your biggest challenge right now?

For example: Anxiety, low self-esteem, period pains, etc (Try to pick one MAIN challenge to focus on)

How do you want to feel after completing your 2-week self-care routine?

For example: More confidence, better sleep, more grounded, etc

How would you describe your overall health right now?

To what extent do any health issues restrict your daily life?

For example: Depression, surgeries, chronic conditions, accidents.

What is your daily routine in diet and digestion?

What is your daily routine in relaxation and sleep?

*How many hours per night on average do you sleep and in the morning do you normally feel rested?

What do you do for exercise and how regular is it?

How is your stress level right now?

Please select a number on a scale of 1-10, 1 being the lowest stress and 10 being the highest stress

How is your overall energy level from day to day on average?

Please select a number on a scale of 1-10, 1 being the lowest energy and 10 being the highest energy

Do you have any experience with yoga or meditation? If yes, please explain briefly

Are you aware of what triggers your stress for you?

For example: a particular person, an activity, a topic, etc

What helps you cope with stress?

For example: meditation, talking to a loved one, certain foods, etc

That’s all! Thanks for your time. If there's anything else you’d like to share, please enter below…

Thank you for your time. You’ll receive your customized self-care audio routine via email within 2 days! Any questions: Joss@wildwomb.space

INTAKE Form - Self-Care Routine

Assessment Form - Self Care Routine

Assessment Form:

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