Client Intake Assessment Form
A thoughtful first step on your journey toward becoming whole—mind, body, and spirit.
Welcome, Friend
Thank you for choosing Becoming Who You Prefer to Be™. This assessment is designed to help me understand your current season of life, your goals, your challenges, and the person you desire to become.
There are no right or wrong answers. Please answer honestly—everything you share is confidential and will help me personalize your transformation journey.
Take your time. This is sacred work.
What to Expect
This assessment gathers eight areas of insight to guide our first session together.
About You
The essentials—your background, life situation, and how you currently feel.
Current Life & Challenges
How satisfied you are across areas of life and what's weighing on you most.
Emotions & Patterns
The emotions you carry and the habits or patterns you're ready to release.
Identity, Values & Vision
Who you're becoming, what you value most, and the life you're intentionally creating.
Your Intake Assessment
Please complete each section as honestly and thoroughly as you can. Your responses will shape our very first conversation together.
Everything you share is confidential and used only to personalize your journey.
A Personal Note From Netara
"Healing is more than symptom relief. Transformation is more than positive thinking. Wholeness happens when your body, mind, emotions, behaviors, beliefs, and identity begin working together instead of against one another."
— NETARA JACKSON
Back 2 Basics Restored Health & Wellness
Questions Before We Begin?
If anything about the intake process feels unclear, or if you'd like to talk before completing the form, I'm here for you. Reach out anytime.
Email: netara@wellness-restored.com
Phone: netara@wellness-restored.com
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