Intake Assessment

Where Are You
Right Now?

These questions give Jen the data she needs to understand your current state. Answer honestly. There are no right answers — only real ones. Everything here is confidential.

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The 12 Questions

1.On a scale of 1–10, how would you rate your overall quality of life right now?

2.How many hours of uninterrupted sleep do you get on an average night?

3.Are you currently on any medication or heavy supplementation for anxiety, depression, sleep, or pain? If so, what and for how long?

4.How would you describe your emotional state most days in three words?

5.How often do you lose your temper or react in a way you later regret?

6.What does your body feel like when you wake up in the morning?

7.What is the primary relationship in your life and how would you rate its health on a scale of 1–10?

8.What are you currently doing to manage stress? (Alcohol, food, overworking, scrolling, isolation — be honest.)

9.If nothing changes in the next 12 months, what does your life look like?

10.What have you already tried (therapy, coaching, retreats) that didn't work or didn't last?

11.What is the one thing about your current state that you are hiding from your team or your family?

12.If your nervous system stays in this exact state for another 12 months, what is the most likely breaking point you will hit? (Health, marriage, business, etc.)

Where Are YouRight Now?

Where Are You
Right Now?