Hello!
Welcome to Unmedicating Me Coaching! Please take some time to go find a quiet area, grab a fun drink, ground yourself, and get ready to dive in. This form is going to take some time and brain power to get through, but the more information that I have, the better I can serve you. Please answer all questions thoughtfully, and provide as much context as you care to share.
I look forward to working with you!
Kelsey
Demographic Questions
Name
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Age
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Gender
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Are you:
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Occupation
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Children? If so, how many, and how old?
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Country/State
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Medical/Medication Information
Are you currently under the supervision of a licensed healthcare provider?
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Is your provider aware that you are discontinuing your medication?
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Is your provider willing to adjust your medication to a liquid suspension in order to follow the Maudsley Deprescribing Guidelines protocols?
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Please tell me as much as you care to share about your medication journey. Helpful insights include: medication name, dosage, length of use, any diagnoses, etc...
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Are you currently tapering your medication(s)? If so, which medication, how much have you reduced it by so far and over what kind of timeline, and what are your overall goals? (eg. completely coming off, just lowering overall dosage, coming off of one medication but staying on another)
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If you have every stopped your medication abruptly, please explain below:
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Have you every experienced any withdrawal symptoms if you have stopped your medication and/or tapered off? If so, what are your common symptoms, and the severity?
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What is your primary motivator in wanting to reduce or discontinue your medication(s)?
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Have you ever been successful in lowering your dosage(s) before?
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Lifestyle Questions
Tell me about your morning routine, before work:
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Tell me about your daytime routine, during work:
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Tell me about your afternoon/evening routine, after work:
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Tell me about your bedtime routine:
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How much time do you spend on a screen during the day:
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How would you describe your overall quality of life with your current routines?
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Sleep Questions
What time do you normally get in bed, and how long does it take you to fall asleep?
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Tell me about your sleep quality:
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When you wake up in the morning, do you feel rested?
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Do you take anything to help you fall and/or stay asleep? If so, what?
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Describe your energy levels during the day:
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Nutrition Questions
Describe your normal breakfasts:
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Describe your normal lunches:
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Describe your normal dinners:
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Any snacks/treats?
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Do you drink caffeine? If yes, what, how much, and when?
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How much water do you consume each day?
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Do you have any current GI/digestive symptoms?
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Do you drink alcohol? If yes, what, how much, and when?
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Do you take any supplements (herbal and nutritional)? Please list them below:
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Exercise Questions
Are you currently engaged in a regular exercise routine? If yes, what and how often. If no, are you interested in starting one?
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Do you feel your body is currently:
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Are you more likely to exercise in the morning, afternoon, or evening?
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What would your ideal exercise routine look like? Include what, when, and where.
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Mood and Behavior Questions
On a scale of 1-10, how stable do you feel right now? (1 = extremely unstable, 10 = very stable)
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Have you ever experienced the following symptoms?
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What symptoms are bothering you the most right now?
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How would you describe your mood on a good day:
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How would you describe your mood on a challenging day:
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On average, how stressed do you feel most days? 1-10
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Do you practice any of the following?
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When you feel anxious, what do you typically do?
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Do you believe that our internal dialogue can affect our overall mood?
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Is your mood steady during the day, or does it "peak"? If so, does it peak in the AM or PM?
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Have you ever experienced:
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Coaching Questions
Do you feel like you know who you are without medication? Please explain.
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What are you most excited for in this process?
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What are you most afraid of in this process?
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What are you hoping will improve? What are your medication/symptom goals?
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How ready are you to work on the following areas? (1= not ready, 10, very ready)
Nutrition
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Exercise
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Sleep
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Stress Management
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Routines
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Home Stretch!
Are you willing to remain under medical supervision?
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Do you understand that this coaching relationship will focus on lifestyle and nervous system regulation, not medication management?
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You did it! YEAH! Take a moment to close your eyes and take a deep breath. Right now...
Ahhh... welcome back. :)
From here, I will take some time to review your form. Please understand that it may take me 5-7 business days to get this back to you with your coaching plan. I will send it to you via email as well as upload it to your Coach Accountable portal.
In the meantime, all of the heavy lifting on your end is done. Drop your shoulders, unclench your jaw, take your tongue off the roof of your mouth. (I know it was there...!)
I will be in touch soon. I genuinely cannot wait to work with you.
Be well,
Kelsey