Client Intake From

Thanks for trusting me and taking the time to fill this out.

All information stays confidential. I use this to understand your current state and tailor our sessions to your specific needs for a safe, effective experience.

I'll reach out within 5 business days to schedule our initial session, where we'll review your responses, ask questions, and do some movements so I can better understand what you need.

By submitting this form, you're committing to your chosen package. If we're not the right fit after our first meeting, simply email [email protected] within 48 hours.

I look forward to working together to achieve your goals.

* My availability opens on Oct 14,2025 and onwards: Weekdays(Monday to Friday).

* My time zone for your reference if we live in different time zone:

From mid-March to early November, Pacific Daylight Time (GMT-7)
From early November to mid-March, Pacific Standard Time (GMT-8)

* Beta test details are by invitation via email. Spots are limited, first-come, first-served. Open to new customers ONLY.

Personal Information

First Name *

Last Name *

Email *

Age *

You can put an age range if you prefer not to say your exact age

What do you do for work? *

Which service are you interested? *

Beta Test (6 sessions), spots limited, first-come, first-served. New customer ONLY.

Bliss Move Package (6 sessions)

Strong & Confident Package(12 sessions)

Current Situation

How do you rate your stress level? (Select the option which best applies to you) *

Low

Medium

High

Very High

Where do you experience pain on your body? *

How would you describe the pain? What is the intensity of the pain on a scale of 1-10(with 10 meaning unbearable pain)? What aggravates the pain? What helps to relieve the pain? *

Example describing pain: pinching, pulling, sharp, dull, compressing, cramping etc.

Are you currently receiving any treatment? Or have your received any treatment before? How do/did the treatment work for you? *

How you feel about your symptoms? What emotion arise when you experience pain? *

such as: frustrated, annoyed, anxious, stressed, overwhelmed, hopeless etc.

What has been your biggest struggle with the pain and how has it affected your quality of life? Or What "life things" do you want to get back to or wish to enjoy more? (ex: feel more energetic, be able to do "X", be ready for anything physical) *

How often do you engage in the forms of physical activity described above? *

Not currently active

2-3 times per week

4-5 times per week

Every day

What have you tried to relief the symptom? What do you think that is not working for you? What made you decide to reach out to me at this time? *

What are you doing right now when it comes to physical activity? *

If you're not currently or not consistently active, think back to physical activities that you might have done in the past. What were they? What did you enjoy about them? What made you stick to them? (Write "N/A" if you've never been active) *

Medical History

If you've checked any of the conditions listed above, please describe them in more detail. Please also list any conditions not mentioned above

Have you ever had any surgeries? If yes, please list what they were and when they took place *

Are you currently taking any medication (prescribed or otherwise) or any supplements. If yes, please list them *

Service Preferences

What session frequency did you have in mind? (minimum is once per week) *

1 session per week

2 sessions per week

Which city and country are you located. What is your time zone?(If I invited you to provide my service in-person, you can skip this one.)

Ex: California, USA, PDT or GMT-7

What do you think would make our sessions more personalized (ie: music we listen to, areas we focus on, exercises we do/not do, themes, etc)? *

What do you want to learn about when it comes to human body, movement and wellness in general? *

What is your availability for conducting our sessions during the weekdays AT YOUR LOCAL TIME? Morning, daytime, afternoon, evening? Any time frame? Are you flexible in this regard? *

Is there anything else that you want me to know?

IMPORTANT (please read, then tick the box)

By submitting this form, you are committing to finishing the package you choose with me. If you feel we're not the right fit after our first meeting, you will let me know in person or by email [email protected] within 48h.

[email protected]

Blogs

41 Ideas to Stay Active and Fit – Level Up Your Health

I have collected a big list of 41 exciting ideas to stay active and fit that will make exercise fun! Whether you like trying out new skills or sticking with your favourite activities, to keep you moti... ...more

physical health

December 19, 2024•16 min read