Intake Opt in Form ONLY

I am attracting the relationships I really want. (Check 1 for not at all, 5 for absolutely!)

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I feel confident about myself (Rate from 1-5)

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I have all the support I need in my life. (Rate 1-5)

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I know what I want in partnership. (Rate from 1-5)

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How committed are you to making lasting changes in your relationship to your body, and sexuality ? 1 is low, 10 is high

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I feel emotionally balanced. (Rate from 1-5)

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I have a great relationship with my own body. (rate 1-5)

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I understand my hormonal cycle and feel they are in balance.. (Rate from 1-5)

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I feel empowered to make good choices for my health & life. (Rate from 1-5)

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I nourish myself daily with food, exercise & awareness. (Rate from 1-5)

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I feel great about my sexual desires and can express them easily. (Rate from 1-5)

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Dr. Willow Brown's Intake Form

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