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Client Intake Form

Personal Information

Health and Wellness Background

Have you been diagnosed with or are you currently experiencing any of the following conditions? (Check all that apply)

Lifestyle and Habits

How would you rate your current stress levels? (1 being very low, 10 being very high)

Goals and Expectations

Support and Accountability

How do you prefer to receive support and communication during the program?

Additional Information

Consent and Agreement

By completing and submitting this form, you agree to participate in the Brain Retraining Program under the guidance of

You understand that this program is not a substitute for professional medical advice, diagnosis, or treatment.

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Contact Me

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Main Contact Page

contact@shonnastokowski.com

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Alberta, Canada (MST)

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DISCLAIMER

The content in this website is purely for informational purposes only, and is NOT a substitute for medical diagnosis, treatment or advice. Please consult with your doctor if you are unsure about whether you should undertake the Gupta Program or coaching.

Results are not guaranteed from doing the Gupta Program or undertaking Gupta Program Coaching.

© 2021  Shonna Stokowski

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