Wellness Coaching Questionnaire

Wellness & Embodiment coaching intake form.

Thanks again for your interest in coaching! These quick questions will help me understand your current habits, goals, and how I can best support your transformation. Be as honest as possible — no judgment, just a fresh start. I will be in touch with you within 24 hours! Looking forward to get you started on your new lifestyle! (PS: Filling out this wellness evaluation does not commit you to the program.)
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Format: (000) 000-0000.
Instagram handle
Age*
years
Height*
cm
Current Weight*
Lbs
What are your top 1–2 goals right now when it comes to your health, energy, or daily habits?*
Nutrition & healthy eatingFitness/movementMindset & motivationBuilding a consistent routineAccountability & structureSelf-confidence
What’s your current relationship with movement or fitness like? (Be as honest and open as possible)*
What have you tried before and why did it not work for you?*
Less than 22 - 34 or more
None (seated all day)Moderate (light activity such as walking)High (heavy labor, very active)
Yes, I currently doYes, I haveNo, I have not
Have you ever used any supplements, protein shakes, or wellness products before? If yes, which ones and how did they work for you?*
1-33-5over 5never
1 glass2-3 glassesfull gallon alwayswhat's water?
TeaJuiceSodaCoffee/Energy Drinks
Right when I wake upMid-dayAfter workOther
12345678910
Why?*
What has prevented you from reaching your goals in the past?*
Please detail if you have ever tried a program or diet before.*
1-1 coaching21 day fitness challenge (group & community support)A plan to follow independentlyNot sure I’d like to discuss
What’s one change you’d love to make in the next 30 days that would make you feel proud of yourself?*
CallTextEmailOther
Congratulations in taking this first step filling out the intake form! I am looking forward to working with you! I'll reach out within 24 hours!
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Wellness & Embodiment coaching intake form.