Health Coaching Intake Form Date * MM DD YYYY Name * First Name Last Name Preferred Name Preferred Pronouns Date of Birth * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Phone * (###) ### #### Ok to receive texts? * Yes No What is your prefferred method of communication for coaching sessions? * Video Call Phone Call Emergency Contact * Please provide Full Name, Relationship, Phone Number, Email Please share anything that would be helpful to know prior to our first session * beliefs, identities, culture, lifestyle, values, and/or current situation you would like me to know about that impact/influence your health and wellness, decision-making, and ability to make progress (N/A if you can’t think of any) What areas of health do you feel you need the most support with? * Nutrition Exercise/Physical Activity Stress Management Sleep Emotional Well-being Weight Management Energy Levels Other If you selected "other" above, please specify: What are your primary health and wellness goals? * Current Health Snapshot/Assessment: Please rate your overall satisfaction in each category on a scale of 1-10, 1 being low and 10 being high, where you currently are today. There is no good or bad answer, just information. Movement/Physical Activity * 1 2 3 4 5 6 7 8 9 10 Sleep * 1 2 3 4 5 6 7 8 9 10 Stress Coping * 1 2 3 4 5 6 7 8 9 10 Healthy Eating * 1 2 3 4 5 6 7 8 9 10 Relationships * 1 2 3 4 5 6 7 8 9 10 Social Connection/Community * 1 2 3 4 5 6 7 8 9 10 Environment (surroundings and sustainability) * 1 2 3 4 5 6 7 8 9 10 Finances * 1 2 3 4 5 6 7 8 9 10 Career/Service * 1 2 3 4 5 6 7 8 9 10 Spirituality * 1 2 3 4 5 6 7 8 9 10 Fun/Leisure/Creativity * 1 2 3 4 5 6 7 8 9 10 Growth/Learning * 1 2 3 4 5 6 7 8 9 10 Healthcare Adherence (Visits, following prescriptions, etc.) * 1 2 3 4 5 6 7 8 9 10 Thank you! Your response has been submitted.Please use this link to book appointments (session 1 & follow-up sessions).
