CARLEN’S COACHING + CONSULTING INTAKE FORM

Hi it’s Carlen! Thanks for wanting to work together!

I am honored to help you!

Below is the intake form I would like you to fill out before our session as best as you can. Everything you share is confidential and safe with me.

Whether your session is focused on Integrative Health or addressing a specific creative project or spiritual issue you would like my assistance on, the answers to these questions below will help me A LOT to get to know you better and ensure that we are able to use our time together as optimally as possible!

There is no wrong answer to these questions.

Along with this form, payment is due prior to each session.

The cost for an Introductory 1 hour phone consultation is $144 which includes a PDF write-up of any suggestion I have for you to meet your goals.

You can send payment via Paypal (workwithcarlen@gmail.com) or Venmo (@carlen-altman) prior to our appointment.

Once this form below is reviewed by me and payment is received, I will send you an option of available booking dates for us to make it a reality!

I am on EST time (New York City) just an FYI!

Our session will take place via phone, using either Wifi Calling, Telegram (most preferable), Zoom Audio, or Google Calling.

Note: All information shared during our session together is for educational/informational purposes only. Please see my DISCLAIMER for more legal information before agreeing to work with me to make sure we are on the same page as to what my work entails.

Thank you!

LET’S GO FOR THE GOLD!

(Cue Rocky Theme music! as you fill out the form below!)

Name

First Name

Last Name

Phone

(###)

###

####

Date of Birth (for Human Design)

YYYY

Birth details: What exact time were you born? And exact location?

How did you hear about Carlen/1-800 EARTH?

Are you a student, unemployed, employed, a stay at home parent or something else? What do you do during the day?

What brings you to a session with me?

What are your goals when working with me (in order of goal importance?)

If you could have anything or experience, what would it be?

Any health issues you are experiencing or have experienced which you wish to share?

Have you experienced anything scary or traumatic that you think may be impacting you? (Feel free to elaborate as little or as much as you feel comfortable).

This may seem random but what is your blood type?

What vitamins AND/OR minerals do you take, if any and what dosage and brand?

What did your diet look like this week? Please describe in as much detail as possible (no judgement!)

How much water do you drink and is it filtered? If so, what kind of filter?

Do you have an exercise routine of any kind? Please describe

Do you have a spiritual connection or practice? No judgement either way but please share more!

What is the funniest joke or video or movie you have ever seen?

Have you ever done a detoxification or cleanse of any kind? What type and brand? Did it help?

Have you taken psychedelics or plant medicine? What are your feelings about them? (No right or wrong answer!)

Is there anything else you would like me to know about you or your concerns?

Do you agree to the Client Agreement Policy Terms & Conditions?

You agree that this appointment is for Informational/Educational purposes only and not meant to replace the role of your Physician/etc. To proceed with booking, please read the full Agreement at https://carlenaltman.com/clientlegal and only click Yes if you agree.

Yes I agree

No and/or I need more info

CARLEN’S COACHING + CONSULTING INTAKE FORM

Our session will take place via phone, using either Wifi Calling, Telegram (most preferable), Zoom Audio, or Google Calling.

LET’S GO FOR THE GOLD!

Thanks For Being Here!

LOVE,

CARLEN