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Stepping into your second act (your next phase of health, vitality, and personal renewal—typically in your 30s, 40s, 50s, and beyond) is an opportunity to reclaim your health, vitality, and confidence—but navigating this transition can feel overwhelming. You don’t have to do it alone.This consultation is your first step toward gaining clarity, understanding your body’s unique needs, and creating a personalized strategy for lasting well-being.

To ensure I can provide the most insightful and effective guidance, please take a few moments to complete this form. Your responses will help me better understand your current challenges, goals, and health history.

Once submitted, I will review your information and reach out within three business days to schedule your consultation. I look forward to connecting with you and helping you step into your second act with confidence, energy, and resilience.

Thank you for taking this step toward empowered, proactive health!

First name

Last name

Phone

Time Zone

Birthday

Month

Day

Year

How would you describe your current menstrual status?

Premenopause (having regular periods)

Premenopause (no periods due to hormonal birth control)

Perimenopause (having irregular periods &/or symptoms)

Perimenopause (symptoms but no periods due to hormonal birth control)

Postmenopausal (no periods in over 12 months)

If postmenopausal, was it:

N/A

Spontaneous (occurred naturally)

Surgical (removal of both ovaries)

Due to chemotherapy or radiation therapy

Age at first menstrual period

Age your mother finished menopause?

If you are not able to contact your mother please put I don't know.

Do (or did) you experience PMS?

Yes

I don't know

Please describe your menstrual periods:

Light, heavy, short, long, irregular, painful, etc.

What reproductive organs do you currently have?

Both Ovaries

Cervix

Uterus

Select all that apply

Do you conduct regular breast self-exams?

Yes

What supplements and/or medications are you taking specifically for women's health and/or menopause?

Please also note if you are on HRT and/or SSRIs.

Have you had a bone density tests or screenings related to menopause health?

How many hours of sleep do you average per night?

≤5

6-7

Symptom Experiences

Below are all potential symptoms that you could be experiencing during perimenopause and beyond. Please take your time to go through each one and answer the most fitting answer as of now:

How would you rate your typical energy levels?

Low

Moderate

High

At what age did you begin experiencing these symptoms?

How do you view menopause?

Positively

Negatively

Neutral

Describe your peri/menopausal experience so far:

What are your concerns about menopause?

What are your views regarding menopausal hormone replacement therapy?

Have you experienced a traumatic event in the last 5 years?

Such as loss of a loved one, job changes, divorce, relocation, etc.

What else would you like us to know about your experience that wasn't covered above?

What would be your ideal outcome from working together?

Yes, subscribe me to receive exclusive educational resources, expert tips, and personalized support designed specifically for my menopause journey.

I acknowledge that I have read and agree to the terms of the Liability and Scope of Practice Waiver. I understand that coaching services do not replace medical advice, and I take full responsibility for consulting my healthcare provider as needed.

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Symptom Experiences

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