PRE INTAKE FORM Thank you for scheduling the intake call! Please fill out these brief questions beforehand so we can best prepare for our conversation. Please make sure to submit these at least 2 days before our call. First nameLast name *Email addressConfirm email addressPhone number *What are you currently struggling with the most in your daily life, and what specifically do you want to work on during this journey? *Do you experience inner restlessness, a constantly "on" nervous system, or emotional overwhelm? *Do you struggle with unhealthy or destructive lifestyle habits? *For example: emotional eating, smoking, alcohol, poor sleep, overworking, or isolating yourselfWhat do you want to achieve through this coaching, and how would your life look and feel once you reach that point? *Are you currently experiencing severe mental or physical health issues, receiving treatment from a medical specialist or psychologist, or having thoughts of self-harm/suicide? *Note: MYNERSE provides holistic coaching for healing, growth, and sustainable change. It is not a substitute for professional medical or psychological care. IF YES, PLEASE EXPLAINSend
