New Client Intake Form — Chef Maria Cooper

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City, State

What is your current breakfast, lunch, dinner like during the week? Weekends?

How full/busy is your life currently with work, family responsibilities and/or other responsibilities? Give me an approximate sense. This helps me to see the possibilities for cooking/shopping and strategies we can adopt to nourish you the best with your current lifestyle.

How often are you cooking meals? Eating out/Ordering take-out?

What kinds of foods are in your fridge, freezer, and pantry currently that you prepare/eat regularly?

Do you have any goals with your food and diet specifically?

Common goals: ‣ Increased energy ‣ Clarity of mind ‣ Mood balancing and stabilizing ‣ Blood sugar stabilization ‣ Losing or gaining weight ‣ Increasing nutrient density ‣ Simplifying food preparation ‣ Enhance the quality and flavor of food I cook! ‣ Your own personal goals (list specifically)

Have you seen any doctors/done testing for food allergies or food intolerances? Have you been advised by a particular doctor to eat a particular type of diet different from what you are currently eating? More specifically, for a medical reason, are there any foods on your “no-can-do” list or “limited” list?

Any health conditions (not listed above) that you feel comfortable sharing about? Especially if it affects your diet and overall wellness that you are aware of.

What time and space, if any, do you devote relaxation and self-care to currently? What does this look like in your life? What do you find relaxing currently in your life? Do you spend time in nature? Tell me more.

What are your goals with Nourishment Coaching (if you know)?

What does "Health" mean to you, as the individual that you are? What in your life is helping you to achieve your health goals, or impeding your path toward health?

Top 5 favorite ingredients (taste, texture, etc...)?

Least 5 favorite ingredients?