Jonah Berger Coaching ·
Intensive Coaching
Intake Questionnaire
This isn't a form to fill out correctly. There are no right answers. The goal is an honest picture of where you actually are — not where you think you should be.
Section 01
The Basics
Starting with the straightforward stuff — who you are and what's bringing you here.
Your name
Age
In one or two sentences, what's bringing you to this program right now?
Don't overthink it. First honest answer.
How long have you been aware that something needs to change?
Less than 6 months
6 months to a year
1 to 3 years
More than 3 years
I've known most of my life
Have you worked with a coach, therapist, or counselor before?
No, this is new
Yes — therapy or counseling
Yes — coaching
Yes — both
If you've worked with someone before — what helped, what didn't, and what happened?
Skip if not applicable.
Section 02
The Pattern
What's actually happening day to day — and what it's been costing you.
A note before this section
These questions are designed to get underneath the surface behavior. You don't need to present yourself in the best light. The more honest you are, the more useful this will be.
Which of these show up regularly in your life? Select all that apply.
Sleeping too much or at irregular times
Eating late or skipping meals
Little to no exercise
Excessive phone or screen use
Gaming as primary downtime
Difficulty starting things I intend to do
Withdrawing from people
Low motivation most days
Anger or irritability I don't fully understand
Numbing out when things get hard
Difficulty finishing things I start
Feeling stuck while watching others move forward
When you reach for your phone, gaming, or go-to escape — what are you usually moving away from?
What's the feeling, thought, or situation that precedes it?
What does a typical day actually look like for you — from when you wake up to when you sleep?
Not the ideal day. The real one.
What's the gap between the life you have and the life you imagine for yourself?
What specifically is missing or hasn't happened yet?
How many times have you tried to change some version of this pattern?
This is the first real attempt
A few times — 2 or 3
Many times — I've lost count
I haven't really tried — mostly just thought about it
What happened the last time you tried to change something significant?
What started well, where did it fall apart, and what did you tell yourself afterward?
Section 03
Body & Biology
Sleep, food, and movement are the entry point for this work. This section establishes where you actually are with each.
Sleep — rate the quality of your sleep over the past month
1 = severely disrupted, no routine · 10 = consistent, rested, regular
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Severely disruptedConsistent and rested
Describe your current sleep pattern
What time do you typically sleep and wake? Is it consistent? What's happening in the hour before bed?
Food — rate the regularity and quality of how you're eating
1 = no routine, skipping meals, eating late · 10 = consistent timing, adequate intake throughout the day
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No routineConsistent intake
Walk me through what you typically eat and when
Include late-night eating, skipped meals, anything that feels like a pattern — good or bad.
Movement — how would you describe your current physical activity?
Essentially none — sedentary most days
Occasional walks but nothing structured
I exercise sporadically — inconsistently
I exercise regularly — at least 3 times a week
What's your relationship with the gym or exercise?
Not what you think you should feel. What actually comes up when you think about going.
Is there anything about your body right now that's a source of stress, embarrassment, or preoccupation?
Weight, appearance, health concerns — anything you're carrying quietly.
Section 04
Inner World
What you believe, what you feel, and what you're carrying that you may not be saying out loud.
Why this section matters
Behavioral change fails most often not because of lack of effort but because of what someone believes is actually possible for them. These questions are designed to surface that honestly and without judgment.
On your most honest days, how much do you believe this program — or any program — will actually make a difference for you?
1 = I don't really believe it will · 10 = I genuinely believe change is possible for me
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I don't believe it willGenuinely believe change is possible
What would have to be true for you to feel genuinely good about yourself?
Not what you've been told. What do you actually believe needs to happen or change?
What's the fear underneath the pattern — the thing you're most afraid will still be true even if everything changes?
Take your time with this one.
Which of these are present for you regularly? Select all that apply.
Anxiety or persistent worry
Low mood or depression
Feeling like things are futile or pointless
Shame about where I am at my age
Anger I don't fully understand or control
A sense that I'm falling behind everyone else
Difficulty feeling anything much at all
Existential dread about the future
Self-criticism that's hard to turn off
Difficulty trusting that things can actually be different
Is there anything in that list you'd like to say more about?
Are you currently experiencing thoughts of harming yourself or not wanting to be alive?
This is asked directly because it matters. Your answer won't disqualify you from anything — it helps ensure the right level of support is in place.
No
Occasionally — passive thoughts, not plans
Yes, and I'd like to talk about it
Section 05
Relationships & Environment
Change doesn't happen in a vacuum. The people and systems around you either support or complicate this work.
Who do you currently live with?
How would you describe the emotional climate of your living situation?
Supportive and low-stress
Neutral — people mostly leave me alone
Tense or unpredictable
People are invested in me in a way that adds pressure
It's complicated — hard to put in one category
Do the people you live with know you're doing this program?
Yes, and they're supportive
Yes, but it feels like pressure more than support
They know I'm working on things but not the details
No — I'd prefer to keep this private
Has anyone in your life become involved in managing or monitoring your behavior — even with good intentions?
e.g. holding your phone, checking on you, expressing disappointment when you fall short.
How do you typically respond when someone expresses concern or frustration about your patterns?
I shut down or withdraw
I get defensive or angry
I agree in the moment but nothing changes
I feel shame and then spiral
I take it seriously and it actually moves me
Is there anyone in your life right now who you feel genuinely seen by — not managed, not judged, just seen?
Is there a romantic relationship currently, or a significant absence of one that's on your mind?
Either is relevant — you don't need to explain it, just name what's true.
Section 06
Readiness
The last section. These questions are about what you're actually bringing to this — and what you need from it.
What would make this program feel like it worked — even if nothing else changed?
Not the full picture — just the one thing that would feel like real evidence of something shifting.
What do you think is most likely to get in the way of this working?
If you were betting against yourself, what would you bet on?
How comfortable are you with someone being in the field with you — at the gym, in your kitchen, present in the actual texture of your day?
Very comfortable — that's exactly what I need
Somewhat comfortable — it'll take some getting used to
Uncomfortable but I'm willing
I'm not sure — I have some resistance to it
Overall readiness — how ready are you to actually do this, not just think about doing it?
1 = thinking about it but not ready · 10 = I'm done waiting, ready to move
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Thinking about itDone waiting
Is there anything you want me to know going into this that you haven't had a chance to say?
Anything important, anything you're worried won't come up, or that you want on record before we start.
Complete
Your Responses
Review everything below. When you're ready, hit Submit — your responses will be sent directly to Jonah.
Once you submit, a copy of your responses goes directly to Jonah at [email protected]. You can also print or save a copy for yourself.