Start your journey with Michelle, a compassionate menopause coach. Complete the intake form to schedule your personalized consultation and support plan.

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Confidentiality and Privacy Disclaimer

Your privacy is important to us. All information provided in this form is strictly confidential and will only be used to support your coaching experience. It will not be shared with any third party without your explicit written consent.

Full name

Date of Birth

Year

Month

Day

Phone

Preferred Method of Communication

Emergency Contact (name, relationship, phone #)

Are You Currently Experiencing Menopause Symptoms (if yes, describe)

At what age did you begin experiencing symptoms?

Have you been diagnosed with menopause by a healthcare provider?

Yes

Are you currently taking any medications or supplements? Please list:

Do you have any chronic health conditions?

Yes

Describe

Describe your current diet and exercise routine:

Do you smoke or consume alcohol? If yes, how often?

How would you describe your current emotional state?

Are you experiencing mood swings, anxiety, or depression?

Do you have a support system (family, friends, community)?

What are your primary goals for menopausal coaching?

What areas would you like to focus on (e.g., symptom management, lifestyle changes, emotional support)?

What outcomes would you like to achieve through coaching?

Additional Information