Kara | Client Intake Form

Section 1 of 5

About you

Let's start with the basics so I can get to know you.

First name

Last name

Email address

Phone number

Age

Location / timezone

How did you hear about Kara?

Is there anything important you'd like me to know before we begin?

Section 2 of 5

Your journey

Understanding where you are in your menopause journey helps me tailor everything to you.

Where are you in your menopause journey?

Perimenopause — my cycle is changing but hasn't stopped Menopause — it's been 12 months since my last period Post-menopause — I'm through the other side Surgical or medically-induced menopause Not sure — I'm here to find out

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Are you currently using any hormone or menopause treatments?

Yes — HRT (hormone replacement therapy) Yes — natural / herbal supplements No — and I'd like to explore options No — I prefer not to use hormonal treatments Not sure yet

Have you worked with a coach, therapist, or healthcare provider for menopause support before?

In your own words — what is your experience of this time in your life?

Section 3 of 5

Body & symptoms

Tick anything you're currently experiencing. You don't need to have all of these — every woman's experience is unique.

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Emotional & mental symptoms (select all that apply)

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Any other symptoms or concerns you'd like to share?

Section 4 of 5

Your lifestyle

Your daily rhythms tell me so much. This helps me meet you exactly where you are.

How would you describe your current sleep?

How would you describe your current relationship with food?

How active are you currently?

I attend yoga or movement classes regularly I walk or move gently most days My activity is mixed — some weeks more than others I'm fairly sedentary right now I used to be active but have stepped back

Do you have any existing health conditions or take any regular medications?

This information is kept completely private.

Section 5 of 5

Your goals & hopes

This is the most important part. What do you really want from this journey together?

What are your main hopes for working with Kara? (select all that apply)

Understand what's happening in my body Manage my symptoms naturally Feel more like myself again Improve my sleep Find a movement practice that supports me Nourish my body with food Manage stress and anxiety Reconnect with my sense of self Find community with other women

How do you feel about this stage of your life right now?

Curious and open — I'm ready to explore this Cautiously hopeful — I want support but feel unsure Overwhelmed — I'm not sure where to start Frustrated — I've been struggling for a while Mixed — it's complicated

If you could change one thing about how you feel in your body right now, what would it be?

Is there anything else you'd like Kara to know before your first session?

Welcome, beautiful soul

About you

Your journey

Body & symptoms

Your lifestyle

Your goals & hopes

Thank you, beautiful.