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 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)

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 Option are you interested? *

Bliss Move ( USD $499 )

Strong & Confident ( USD $899 )

Pain and Symtoms

Where do you experience pain on your body? *

Does the pain feel more like muscle cramping/pulling, or more like nerve sensations?

Muscle cramping or pulling

Nerve sensations (tingling, burning, shooting)

A mix of both

I'm not sure

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

Examples: pinching, pulling, sharp, dull, compressing, cramping etc.

Have you noticed any patterns for what triggers or worsens the symptoms? *

Examples: sitting too long, certain movements, stress, weather, time of day, etc.

What helps relieve the symptoms, even temporarily? *

Example: stretching, heat, rest, movement, massage etc.

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How pain/syptoms affect your life?

What daily tasks are harder to do now because of your pain? Or are there any movements that feel particularly hard or difficult for you? *

Examples: sitting at desk, getting out of bed, picking things up, driving, cooking, bending forward, twisting, getting up from floor, reaching overhead, squatting, walking up stairs, etc.

What activities or "life things" do you want to get back to or enjoy more? *

Examples: hiking, playing with kids, traveling comfortably, exercising without fear, sleeping well, etc.

What emotions come up when you experience pain? *

Examples: frustrated, anxious, hopeless, annoyed, scared, angry, sad, overwhelmed, etc.

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

Low

Medium

High

Very High

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Your current movements/ activities

What physical activities are you currently doing (if any)? *

Include frequency. Write "None" if you're not currently active.

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

Are there any movements you enjoy or that help you feel better? *

These are movements that feel good in your body or help relieve symptoms

Are there any movements you don't enjoy — even if they don't cause pain? *

These are movements that just don't feel good to you or that you avoid. Write "None" if nothing comes to mind.

When you move, is it easy for your to tell which muscles are working?

Yes, I can usually feel it

No, I often can't feel which muscles are engaging or I didn't pay attention

Sometimes

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Rest & Nerve System

Do you have trouble truly resting or relaxing? *

Yes, I find it hard to do nothing

Sometimes — depends on my stress level

No, I can relax easily

Do you experience anxiety or restlessness when you're not doing anything? *

Yes, often

Sometimes

Rarely or never

What do you currently do to rest or recover?

Examples: napping, reading, meditation, watching TV, walking, nothing specific, etc.

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Your experience with other professionals

Have you received any treatment for this condition? (past or current) *

Examples: physiotherapy, chiropractic, massage therapy, acupuncture, doctor visits, etc. Write "None" if you haven't seen anyone.

What have you learned about your body from those professionals? *

Any insights, diagnoses, or explanations they gave you. Write "N/A" if not applicable.

If you stopped seeing a health professional, what made you stop or keeps you from going back?

Examples: too expensive, didn't help, inconvenient, felt better, couldn't find the right person, etc. Write "N/A" if not applicable.

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

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 *

Working with me

What do you most want to improve by working with me? *

In your own words, what's your main goal?

What do you want to learn about when it comes to your body, movement, and wellness?

If we meet online, what props or equipment do you have at home? *

Examples: yoga mat, foam roller, resistance bands, yoga blocks, tennis ball, chair, towel. Write "None — that's okay too!" if you don't have anything.

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Scheduling

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

1 session per week

2 sessions per week

What is your time zone?

PST (Vancouver), EST (Toronto), GMT+8 (Singapore). Skip if meeting in-person.

What days of the week and time ranges work for you? *

⚠️ IMPORTANT: Please list SPECIFIC DAYS and TIME RANGES at your local time. Example: "Tuesday 6-8pm, Thursday morning 9-11am, Saturday flexible"

Is there anything else you want me to know before we meet?

IMPORTANT (please read, then tick the box)

By submitting this form, you are committing to finishing the services 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]

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