CYS Client Intake Form

You just took your first step toward creating your state. Thank you for being here.

This takes about five minutes. There are no wrong answers here — the point is to understand where you are right now and whether this program is the right next step for you.

If it is, you will get a link to book a 20-minute conversation with Holland. If it is not, I would rather tell you that early.

Before you start:

What you write here is read by Holland Duell and Alyssa Arroyo, the two founders of Create Your State, and no one else. It is stored in Create Your State's access-controlled Google Workspace, it is never sold or shared, and if you do not go on to work with us it is deleted within twelve months. Full details here.

Create Your State is an eight-week, one-on-one intensive built around the ARC Reset Method™ — a tool for noticing your state, redirecting it, and building the resilience to hold it. The full program is a $1,440 investment, paid in full, working directly with Holland each week.

Section 1 - Who Are You

First and Last Name

Email

Phone Number

*Only used if we need to reach you about scheduling.

Where are you based and what time zone are you in?

Sessions are virtual, so we just need to find a time that works on both ends.

What times of day generally work best for you?

Section 2 - Where are you

Answer these however comes naturally. A few sentences is plenty.

What made you look into coaching right now?

Something usually prompts it — a season, a shift, a pattern you keep running into. What was it for you?

If the next eight weeks went really well, what would be different?

Be as specific or as broad as feels true.

Which of these areas feels most out of balance right now?

Mindset — how I think and talk to myself

Nature — time outdoors, connection to the natural world

Movement — how I move my body

Nutrition — how I fuel

Sleep — rest and recovery

Purpose — direction and meaning in what I do

Relationships — the people around me

What have you already tried?

Whether it worked or not. This tells us a lot.

Section 3 - Readiness

This program asks something of you. These questions help us both be honest about whether now is the right time.

This program is built around a daily practice — small, specific actions you commit to between sessions. How does that land for you

That is exactly what I am looking for.

It sounds hard, but I am ready for it.

I am not sure I can commit to something daily right now.

I was hoping for something lighter-touch.

What are you hoping coaching will do for you

Help me build something that lasts, even if it takes work.

Give me structure and accountability I have not been able to create alone.

Give me a fast solution to a specific problem.

Help me work through something from my past.

Are you currently working with a therapist, counselor, physician, or other licensed provider?

There is no right answer. Coaching works well alongside other support — it just is not a replacement for it.

Yes

I have in the past, not currently

I would rather not say

Is there anything happening in your life right now that you would want Holland to know before you talk?

Only what you are comfortable sharing.