Holistic Wellness Coaching Intake Form Name * First Name Last Name Age * Occupation * Email * Best Way to Contact * Phone Call Text Email Facebook Instagram If best to contact via phone, FB, or IG, please include that contact info here: What do you most want to get from the coaching relationship? * Do you have any apprehension or preconceived ideas of coaching? * What are a few health and wellness goals that you have? (If any) * What is the best way for me to coach you most effectively? What tips would you give me about how to best help you? * In terms of scheduling, what days/times would work for you to schedule our weekly/biweekly check-ins? (These should be about 15-20 minutes). Please note that you can always reach out between those meetings but check-ins will be regularly scheduled meetings to assess progress. * For clients who are going to be participating in face-to-face coaching, do you agree to abide by social distancing/COVID guidelines? (Wearing of masks, sanitizing, cancelling sessions if you begin to experience any symptoms, travel out of state or come in contact with someone who has tested positive for the virus) * * I agree I do not agree N/A - No in-person coaching will occur Fitness: For the following section, rate how well each health & wellbeing statement describes you and then answer the questions below. The more details you can provide, the better! Strongly Disagree Disagree Neutral Agree Strongly Agree Describe a current typical week of physical activity and exercise. What do you believe is your ideal amount of activity and exercise? What are your biggest challenges to reaching/accomplishing your ideal? Nutrition: My diet is exactly where I want it. Strongly Disagree Disagree Neutral Agree Strongly Agree What is your diet like now? What do you know you should eat more of and what do you know you should eat less of? What are your biggest challenges? Sleep: I get a straight 7-8 hours of uninterrupted sleep every night. Strongly Disagree Disagree Neutral Agree Strongly Agree When you don't sleep well, what do you think keeps you up? When do you sleep the best? Stress: The amount of stress I'm under is about average and I manage it well. Strongly Disagree Disagree Neutral Agree Strongly Agree Thank you!
