Intake Form | Rise by Reisman

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First name*

Last name*

Email*

Phone

City/State*

Birthday

Month

Day

Year

What made you want to book a Reset Session? *

What’s the one main challenge you want clarity on during our session? (Example: “I can’t stay consistent with workouts,” “I feel stuck,” “I can’t seem to follow through,” etc.) *

How long have you been experiencing this challenge?*

What have you already tried to address this issue? What worked and what didn’t? *

What typically gets in the way when you try to build or maintain this habit? (Select all that apply) *

Lack of structure

Lack of reinforcement

Low motivation

All-or-nothing mindset

Time management

Fatigue or low energy

Stress or burnout

Distractions

Not knowing where to start

Difficulty maintaining routines

My environment doesn’t support my goals

Other

When do you feel most motivated or capable of taking action? (Time of day or context) *

When do you feel least motivated or most likely to avoid the habit? *

What usually reinforces you to stay on track? (Examples: praise, progress tracking, external accountability, rewards, routine, etc.) *

What typically reinforces stopping or avoiding the behavior you want to build? (Comfort, avoidance relief, scrolling, rest, stress management, etc.)

What does a “good day” of this habit look like for you?

If you could walk away from this session with ONE clear solution or plan, what would it be? *

On a scale of 1–10, how ready are you to implement a new plan? *

Is there anything else you want me to know before our session? *

I understand that this session provides behavior-based insights and habit strategies, not therapy or medical services.

I understand this is a standalone session and does not include the ongoing support of The Rise Method.

I agree to show up honestly and openly so I can get the most out of this session.

Thank you so much for sharing more about yourself and your goals.
You’ll receive an email from me soon with your next steps, payment details, and instructions on how to schedule your session.

I’m looking forward to working with you.

Contact

Rise by Reisman

Founder - Kylie Reisman

Tel: 703-943-8976

Email: kyreisman@risebyreisman.com

Book The Reset Method

Book The Rise Method

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