Pre-consultation questionnaire

Name *

First Name

Last Name

Phone *

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What is the main reason(s) you are seeking support for sleep? *

Select all that apply.

Health concerns

Relationship issues

Reduced sex drive

Cognitive/brain function

Ageing concerns

Hormonal imbalances

Other (please specity)

On average, how many hours a night do you sleep?

1

2

3

4

5

6

7

8

9

10

How would you rate the urgency of addressing your sleep concerns? *

(0 = not urgent, 10 = extremely urgent)

1

2

3

4

5

6

7

8

9

10

How ready are you to make changes to your sleep and nutrition? *

I’m still exploring options

I'm getting ready to take action

I'm fully committed and ready to start

What kind of support are you seeking? *

A step-by-step guide to implement changes on my own

Advice on nutrition and supplements

Ongoing coaching for sleep and nutrition

Combination of the above

How much time are you willing to dedicate each week to work on improving your sleep and nutrition? *

Less than 1 hour

1 - 3 hours

4 - 6 hours

7+ hours

On a scale of 1 to 10, how committed are you to investing time and effort to improve your sleep and overall health? *

1

2

3

4

5

6

7

8

9

10

Preferred Date *

Please let me know your preferred consultation date and I will be in touch to confirm.

MM

DD

YYYY