I give ISA Power permission to send my personal information (that you give below) to the ISA Power coaches.
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We will send your details to the coach with whom you have the intake scheduled. If you choose "NO" than you don't have to fill in this form.
Your name
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First Name
Last Name
Email address
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1. What is your biggest problem (burden) at the moment?
2. Do you have any dreams that you want to fulfill?
3. Which physical health problems do you have right now?
Example: stomach pain, bowel problems, digestions problems, constipation, diabetes, pain, hair loss, heart arrhythmia, high or low blood pressure, bruises etc.
4. Which mental health problems do you have right now?
Example: Stress, no sleep, anxiety, panic attacks, depression, thoughts, worries etc..
5. What kind of counseling/therapy have you had already, or have right now?
If this is your first form of therapy? Please do not fill in anything if this is your first therapy, otherwise please fill in the names of people/organisations you went for help before.
6. What do you expect (wish) from your ISA Power coach?
Example: I hope he/she will be honest, treats me with respects, confronts me when needed, and shares her personal stories of recovery.
7. Are you using any medication at the moment? If so, what?
And are there any side effects? Or did you use any medication in the past?
8. Do you do any sports/exercise?
If so, what kind of sport do you do and how many times a week?
9. Do you experience stress in your life?
If so, how often and when do you experience this?
10. Do you also suffer from other things?
Comorbidity: trauma, stress, anxiety or panic attacks, self-harm, autism, other personality disorder.. etc.
11. Do you smoke, use drugs or drink alcohol?
If so, what do you use/take on a weekly basis?
12. Do you suffer from depression? Or do you feel down sometimes?
Did you ever think of (or tried) to commit suicide?
13. Do you have a stable weight?
Are you on your healthy (set point) weight right now?
14. How would you describe your eating behavior?
What should you do (in all honesty) to improve your health?
15. What do you eat on a ordinary day?
Describe your breakfast + lunch + dinner + snacks and drinks (and other things in between as well)
16. Are you studying or working? If so, what kind of study/job do you have?
If you don't have a job or go to school at the moment, please describe your previous experience or activity.
17. Please describe your family situation.
Do you have siblings/parents/partner? And with whom do you live now? (or alone)
18. When did you develop your eating disorder? At what age?
What kind of eating disorder do you have? Anorexia, Boulimia, Binge Eating or a combination or something else? Please describe for yourself how you see it...
19. What would you do if you would wake up without an eating disorder tomorrow?
Who would you be and what would you do immediately?
20. If you have any other things to share or add, please do it in the field below:
Our mission isn't only to help our clients in the best way possible, but also other caregivers and professionals in this work-field. We would like to send your general practitioner the book 'The wolf in sheep's clothing' (€19,95). This book is written bij Isabelle Plasmeijer.
Do you share our mission? Let us know below whether we can send your general practitioner a free book.
BONUS QUESTION: Do you believe you can recover from your eating disorder?
