Wellness Coaching Form

Wellness Coaching Intake Form

First name

Last name

Date picker

Phone

Address

Yes, subscribe me to your newsletter.

What are changes you would like to make in your life over the next year?

What health goals would you like to accomplish over the next month?

What changes in your life would you like to implement right now?

What do you believe to be your strengths & best qualities? And which strengths would you like to develop?

What obstacles keep you from reaching your goals?

Where do you see yourself in 6 months, when your coaching journey is complete?

Why have you decided to start this journey?

What is your current level of stress in your life? Scale from 1-10. 1= Very Low to 10 =Very High

How would you rate your current quality of life? Scale from 1-10. 1= Very Low to 10 =Very High

Is there anything else you would like to tell me?

I confirm that I have read and understand this consultation form. To the best of my knowledge, all information provided is true and accurate, and I have no medical conditions that would affect treatment.

Signature

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

Getting to know you

Wellness Private Session

What has been your biggest success so far, and what did you do to accomplish it?

What has your biggest challenge been so far, and how did you deal with it?

What have you already done to move toward your goals?

Who has been important in supporting you so far?

Is there anything in particular that you feel is currently holding you back?

How do you think coaching could help you with your life?

What would you say are your biggest strengths and best qualities?

Is there any other information you'd like to share with me?

Client Preferences

Wellness Private Sessions

In order for us to work effectively together, it is useful to know a bit about your personal preferences when it comes to coaching feedback throughout your journey.

Do you prefer video call or face-to-face sessions?

How do you respond to feedback?

How frequently do you feel you need to review your progress to stay on track?

What methods help you to learn most effectively?

How can I best support you throughout this journey?

Thank you for taking the time to answer these questions! I am honored to be apart of your journey. Give yourself gratitude for making this commitment.

A copy of the Client Bill of Rights is attached for my review, and I understand I may request additional clarification at any time.

A Thoughtful Gift for Mind & Body | Buy a Gift Card

Wellness Coaching Form

Wellness Coaching Intake Form

Getting to know you

Client Preferences