Reset360 Circle Intake Form

Reset360 Circle Intake Form

The intake form is intended to provide critical information that you and we can use to base-case your membership in the program and provide confidential, statistical analysis for the group. All of your information will be kept private.

* indicates required response

1. First Name *This question is required.

First Name
Last Name

2. Email address (upon completion, we will send your responses to this email address) *This question is required.

3. Your age *This question is required.

4. Relationship Status *This question is required.

Married
Divorced
Long-Term Relationship
Single

5. Do you have children?

Yes
No

6. Do you have any of the following medical conditions (check all that apply) *This question is required.

7. Did you complete all Resets and Reentry in the current Detox? *This question is required.

Yes
No
If no, what Resets did you not complete? Please enter an 'other' value for this selection.
Why were you unable/did you choose to not complete the above Reset(s)/Reentry Please enter an 'other' value for this selection.

8. Prior to the Detox, how would you describe your diet? *This question is required.

Vegan all the time
Vegan most/some of the time
Vegetarian
Flexitarian (mostly vegan w/occasional animal-based products)
Paleo
GAPS
Other Please enter an 'other' value for this selection.

9. Based on your typical eating habits, how often do you have splurges in your diet? *This question is required.

Never
1-2 times per week
2 or more times per week
Daily

10. Based on your typical eating habits, how often do you drink alcohol? *This question is required.

Never
1-2 times per week
2 or more times per week
Always

11. On a scale from 1 to 5, how close are you being to your ideal weight? (1=very far from ideal weight, 5=achieved ideal weight) *This question is required.

12. On a scale from 1 to 5, rate your current body image (1=very negative; 5= very positive) *This question is required.

13. On a scale from 1 to 5, rate your current sleep quality. (1=very poor sleep quality; 5=best quality of sleep) *This question is required.

14. On a scale form 1 to 5, rate your current energy levels. (1=very low energy; 5=best ever energy level) *This question is required.

15. On a scale from 1 to 5, rate your current mental clarity. (1=very poor, foggy; 5=best, very clear, no fogginess) *This question is required.

16. On a scale from 1 to 5, rate your current food cravings (1=extreme food cravings; 5-no food cravings) *This question is required.

17. How many times do you exercise more than 30 minutes per week? *This question is required.

More than 5 times per week
3 to 5 times per week
1 to 2 times per week
None

18. On a scale from 1 to 5, rate your current moods (1=extremely moody; 5=extremely level moods) *This question is required.

19. On a scale from 1 to 5, rate your current level of stress (1=extremely stressed; 5=no stress) *This question is required.

20. How do you rate your Gut Health?

Awesome- always stable
Good
Variable
Horrible

21. On a scale from 1 to 5, rate how often do you emotionally eat (1=extremely often; 5=never) *This question is required.

22. On a scale from 1 to 5, rate your current muscle and/or joint pain (1=extreme; 5=none)

23. If you experience headaches, how would you rate their intensity (1=extreme; 5=none)

24. On a scale from 1 to 5, rate your typical anxiety level (1=extremely anxious; 5=not at all anxious) *This question is required.

25. On a scale from 1 to 5, rate your typical level of depression (1=extremely depressed; 5=not at all depressed) *This question is required.

26. How would you describe your current state of personal health & wellness?

I have reached my personal health and goals and would like to maintain
I am on track to reach my goals within one year
I am on track to reach my goals but have a long way to go
I am struggling to reach my goals and feel discouraged