Intake Form – Health History

Welcome! I'm looking forward to working along with you for the next 12 weeks. Take your time with this and be as open and detailed as you can. Here are a few pointers: Try not to worry about what I will think. Don’t judge what comes up for you or edit your thoughts in any way. Nothing is too big or too small to mention - everything applies. It's all part of your life. This is important work and it allows me to read it and know you better during our weekly coaching salons (Live Calls). Be as honest with yourself as possible too. As always, everything you share is 100% confidential.

Coaching Contract*
- I understand that this is a coaching relationship that is distinct from therapy and consulting. As your coach, Renee will invite and support your exploration of options, resources, strategies, actions, and choices. I acknowledge that, in undertaking one or more sessions of physical, emotional, spiritual and mental coaching with Renee Jayne, I am responsible for the consequences. It is my job to decide what is useful from them for my personal development.
- I acknowledge that, a minimum of staying connect with Renee if you are unable to make a live call during your 5 months. This is not required. I trust you to show up for yourself and to stay connected when or if you get triggered, or avoidant, as does happen. Calls are recorded. There are no refunds offered for this coaching container and course. What you put into this will reflect back to you. I have your back and will give you my all. It is assumed you will show up and lead yourself to the coaching calls/salons and training content.
- I understand the importance and value to being on time and fully present for my sessions. If on the phone or Skype or Zoom, I agree to be in a quiet, private place for the session. I will refrain from driving, eating, or multitasking during our time together. (If you find it challenging to find physical space or space in your schedule for the coaching sessions, please bring your schedule to our first session so that we may explore the underlying challenges and support you with putting in place a strategy that works for you).
- I will speak the truth to you as I see it. I understand that I can expect Renee to do the same. I understand that this coaching relationship is playground to explore new ways of relating to someone else and myself.
- In this capacity, I understand that Renee, as a holistic health practitioner is not holding herself out to be a Medical Provider (including doctor/physician, nurse, physician’s assistant or any other health professional), Mental Health Provider (including psychiatrist, psychologist, therapist, counselor, or social worker), registered dietician or member of the clergy. Rather, I serve you as a trainer, educator, coach, mentor and holistic practitioner and guide who provides health, life and nutrition education and learning opportunities to all individuals in need of heath advice.
As we begin, it is useful to be sure we are aligned in our understanding of the nature of our coaching relationship. Please check below to indicate you agree:
Name*
First Last
Phone*
Email*
Birthdate*
What time were you born?
Example: 1:54am (ask your mom or dad if you are unsure!)
What city, state (province), country were you born in?
Share your bloodwork, genetic testing, supplement lists
Upload files: If you have info that you think could help me, help you. Please share 🙂 *all info is confidential
Drop files here or

Max. file size: 256 MB.
What's your blood type?
(ask your parents if you are unsure - if possible)
Describe why you registered for Somatic Freedom - What is your core desire for your time here?*
Please be as descriptive as possible.
Why is this important to you right now?*
Really open up and share why you are inspired to take action now.
Explain your current exercise and recreation habits*
Do you have any main health/nutrition concerns? Please describe in detail.*
What is your definition of acting out with food/eating/exercise? Does this definition of acting out help or hinder your recovery?*
List ALL medicines, drugs and/or supplements you are currently taking.*
Look up the word rationalization in the dictionary. What reasons have you invented to explain or justify your behavior with food/eating/drinking/working out? (be specific for each)*
Do you think you have had trauma or abuse - physical, sexual, mental or emotional? If so, explain.*
What are the current stresses in your life? What are the resulting numbing behaviors you use for these stresses?*
Have you lost control with addictive/obsessive/compulsive behaviors in the past? Have you hit bottom? Explain?
Describe your current diet/eating. Be as descriptive as possible (breakfast, lunch, dinner, snacks, cravings, favorite brands, restaurants, beverages, chocolates, etc)*
Do you have any known food allergies or sensitivities?**
How many times a day do you typically have a bowel movement?*
Answer this question: The most important thing I should change to improve my health is*
What inspires you and lights you up?*
Please share anything else that you think I should know in order to support you fully in this program.

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