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Please fill out honestly, to the best of your ability and within 24 hours of our workshop or meeting.

Your answers will help me create a more impactful experience for you.

Name *
What Titles Best Describe You? (Choose as many as you'd like) *
What is Your Main Concern With Sleep? *
Do You Prioritize Sleep Over Other Obligations? *
Example: working late, going out with friends, household chores, etc.
Do You Feel Like You've Accumulated A Sleep Debt? *
Do you feel like you need to "catch up" on sleep?
What Has Been Your Average Daily Stress Level for the Past Month? *
Do You Go To Bed at the Same Time Each Day? *
Without Any Obligations, Would Your Sleep and Wake Times Change? *
Check 'Yes' if your natural tendencies for sleep differ from your actual schedule
Do You Struggle To Fall Asleep At Night? *
Do You Struggle To "Turn Off" Your Brain at Night? *
Out Of The Following Symptoms, Which Do You Consistently Experience? *
Think for the past month. Check all that apply.
How Close is Your Diet to Paleo? *
I.E. Organic, non-processed, lean protein, high-quality fat, lower carbohydrate, and minimal sugar
Do You Take Sleep-Inducing Medications? *
How Often Do You Drink More Than 400mg of Caffeine Per Day? *
Example: 5 Shots of espresso, Two 5 Hour Energy Shots, 1 Starbucks Venti brewed coffee, 2.5 16 fl oz Monster Energy Drinks, 5 8 fl oz Red Bulls, 11 cans of soda)
Do You Drink Alcohol Within 3 Hours of Going to Bed? *
Do You Track Your Sleep with an App or Wearable? *
Which of These Habits Do You Have? *
How Much Time Do You Spend in the Sun Each Day? *
This does not include time spent behind a sunny window
How Much Physical Activity Do You Get Each Day? *
This includes walking, workouts, gardening, laborious chores, etc.
Do You Have a Pre-Sleep Ritual? *
Do You Have a Morning Routine? *
Finally! Do You Feel Like Your Sleep Could Improve? *