Intake Form

Let's map out the benchmark for how you're feeling

Thank you for purchasing the Body Image Blueprint. In preparation for your consult, please complete this intake form so we have a better idea of where you are before our call.

Your name

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My mood is dictated by the number on the scale/ my appearance.
Highly AgreeSomewhat AgreeNeutralSomewhat DisagreeHighly Disagree

I struggle with body image, but it is not on my mind constantly.
Highly AgreeSomewhat AgreeNeutralSomewhat DisagreeHighly Disagree

I have no problem with missing a workout or eating a meal out with friends.
Highly AgreeSomewhat AgreeNeutralSomewhat DisagreeHighly Disagree

I think negatively about myself more often than I think positively.
Highly AgreeSomewhat AgreeNeutralSomewhat DisagreeHighly Disagree

I am constantly stuck in a binge-restrict cycle.
Highly AgreeSomewhat AgreeNeutralSomewhat DisagreeHighly Disagree

I trust my body to do what is best for me.
Highly AgreeSomewhat AgreeNeutralSomewhat DisagreeHighly Disagree

I recognize that I hold worth regardless of my body shape, size, or weight.
Highly AgreeSomewhat AgreeNeutralSomewhat DisagreeHighly Disagree

I move my body joyfully and eat as I please.
Highly AgreeSomewhat AgreeNeutralSomewhat DisagreeHighly Disagree

I am hesitant about beginning this work.
Highly AgreeSomewhat AgreeNeutralSomewhat DisagreeHighly Disagree

I am willing to show up for me.
Highly AgreeSomewhat AgreeNeutralSomewhat DisagreeHighly Disagree

Questions or Need Help?

Contact Us

P.O. Box 434, Salem, NH 03079

united@rayzeawareness.com

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