Assessment

Welcome! I’m excited to partner with you on your health journey! Together, we’ll strive for a healthier, happier you.

Personal Information

Name(Required)

First Last

Email(Required)

Phone(Required)

Current Age(Required)

Where do you work?

Self-Employed / At Home (includes remote positions)

Office Dweller - you head to the office daily

Airport Hopper - your work constantly has you on the go

Combo Platter - I'm here, I'm there, I'm everywhere

What type of work do you do?

The basics - sales, graphic design, movie producer, Barbie's assistant...whatever.

Mailing Address (if in the United States - I'd like to mail you a welcome gift!)

Street Address City State ZIP Code

You're certainly not obligated to provide your address and forego your gift! Let me know if you'd like me to donate it to another applicant instead! It may make her day!

Mapping the Mind

Have you been officially diagnosed with ADHD? Either way, tell me about some of the frustrations you experience with attention and/or hyperactivity.(Required)

Aside from any ADHD symptoms, what other things do you have going on? Do you have any other chronic illnesses or conditions? (Diabetes, Hypertension, Asthma, etc.) Let's see if we can fix them!(Required)

You don't have to get really detailed! I'm not a doctor and won't pretend to be one. But with my research, there are alternative fixes to problems.

Have you tried meditating? If so, can you do it? Tell me about your meditation experiences...good, bad, or otherwise.(Required)

(Meditation is HARD for ADHDers, and it's OK if you can't pull it off! I can't! But there are things we can do instead. THAT is what I'm trying to figure out.

Breathwork. Believer and doer, or not so much? Tell me more...(Required)

Physical Activity

How would you rate your current Physical Health?(Required)

1 - I Need serious help

2 - I try, but I just can't seem to be consistent

3 - I do OK, but there's definitely room for improvement

4 - I'm doing pretty well and am fairly consistent

5 - I'm killing it and I love it! Hear me ROAR!

What are the things that hold you back the most?(Required)

Height

(Example: 5'4")

Have you gotten shorter over the years?

Approximately how much height have you lost?

Current Weight (optional)

You can leave blank if you prefer.

GOAL Weight OR the number of pounds you want to lose.(Required)

How often do you engage in physical exercise or activity?(Required)

Daily

Weekly

Monthly

Rarely

What types of physical activities do you participate in? (Check all that apply.)(Required)

Walking

Running

Biking

Hiking

Swimming

Yoga/Tai Chi/Pilates/Fitness Classes, etc.

Dancing

Sports (basketball, volleyball, surfing, skating, etc.)

Other (whatever that may be - I'll ask you later)

On average, how many hours per week do you spend exercising?(Required)

Do you prefer to work out alone or with someone?(Required)

How much time do you spend outside per week/day? Do you like being outside?(Required)

What is your primary goal for physical activity? (e.g., weight loss, muscle gain, stress relief, etc.)(Required)

Diet/Nutrition

What's your water intake look like each day? Fill me in...(Required)

How much alcohol do you typically drink in a week? Or day? I know that drill, too. And trust me...nothing you say here will shock me.(Required)

How would you rate your current Diet/Nutrition?(Required)

1 - I Need serious help

2 - I try, but I have a stressful life

3 - I do OK, but sheer volume is my problem. I'm STARVING.

4 - I eat fairly well-balanced meals most of the time.

5 - I've got this meal thing dialed in!

Do you have any die-hard cravings you'd like to tackle?(Required)

How many meals do you eat per day?(Required)

One

Two

Three

All Those PLUS Snacks

How often do you consume fast food or takeout?(Required)

Never/Rarely

Occasionally

Weekly

Multiple Times per Week

Do you follow any specific dietary plan? (e.g., Vegetarian, Keto, Paleo, etc.)(Required)

Yes

What's your go-to COMFORT food(s). If you list lettuce here, you're lying.(Required)

Do you take Pre/Probiotics? If Yes - what kind?(Required)

Are you a fan of Sourdough bread? Just curious - and you'll find out why!(Required)

Describe your diet. Be realistic! If it's bad...tell it like it is! You're not getting judged AT ALL!(Required)

Your current eating habits will tell me a TON! Plus, it'll help me figure out what to adjust for you, specifically.

Sleep Habits

How would you rate your Sleep?(Required)

1 - I can't sleep to save my life / heavily drugged

2 - I can get to sleep most of the time but can't STAY asleep

3 - I do OK some nights, but I don't get enough sleep overall

4 - I'm doing pretty well and feel rested most of the time

5 - I have a lot of problems but sleep ain't one of them!

How often do you feel rested upon waking up?(Required)

Always

Usually

Sometimes

Rarely

How many hours of sleep do you get per night on average?(Required)

Do you use any sleep aids? (e.g., prescriptions, pot gummies, melatonin, white noise, etc.)(Required)

Do you have a consistent bedtime routine? if so, briefly describe it.(Required)

What are your biggest complaints about your sleep situation?(Required)

Social Habits

What Social Media platforms are you active on? List all the usual suspects...(Required)

What are the biggest reasons you're on social media? What keeps you coming back for more?(Required)

Denial was yesterday. If you're spying on your ex-boyfriend, I get it! Tell it to me straight!

What do you like doing for FUN with your friends and/or family?(Required)

How many people would you say are your close friends? You know - the people you can turn to when the going gets rough.(Required)

Would you say YOU are one of those friends to them as well?(Required)

Working on any passion projects? Active in any organizations or clubs? Member of anything?

What are your hobbies?

Ideal "down time" is spent doing what?(Required)

What do you do to manage stress? DIG DEEP here! I want to know about all the positive things – like going for a walk. But I also want to know the negative things – like eating a pint of ice cream chased with whiskey.(Required)

Summary

What is your #1 goal in this journey? VISUALIZE what that would look like - and paint me a picture.(Required)

How hands-on do you want me to be? Want an accountability partner, or for me to simply be there if you need me? I have ADHD - I can be kinda chatty. You know the drill. But if you need to do this for YOU...you will have my 100% support from the sidelines.(Required)

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“Turn your wounds into wisdom.”
– Oprah Winfrey

“It always seems impossible until it is done.”
– Nelson Mandela

“You can’t change who you are, and you shouldn’t be asked to.”
– Jonathan Mooney

“I think more things before breakfast than most people think all day.”
– Your ADHD

“You are not alone. There are others going through the same thing.”
– Adam Levine, Maroon 5

“My ADHD speaks for me before I can speak for me.”
– Unknown