Client Intake Form

Client Intake Form
Welcome, I am so glad you have decided now is the time to thrive begin your unique journey to wholeness through achieving balance in the body, mind and spirit. I may suggest changes to your lifestyle, diet, herbs, colour therapy, sound therapy, and other natural therapeutics. By changing your lifestyle and living more harmoniously with nature, you will begin to create within your body the optimal environment for healing. To successfully reach goals and make positive changes it is important that you are an active participant on your path to well-being.

Please note that I am a Coach, not a medical doctor, and I serve only to educate in the system of wellness. Your coaching is not a substitute for medical care, and I will not diagnose, treat, or prescribe for disease or pathological conditions. For specific symptoms I may recommend that your condition be evaluated by a licensed healthcare professional.

If you are under medical care or the care of another healthcare provider, this Coaching will complement the work being done by your other providers. Please do not discontinue use of any medications without first speaking to your Doctor.

The information you provide will be held in the deepest confidence, please fill out to the best of your ability.

Please sign below to acknowledge that the above statements have been fully read and understood.
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Signature

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Health
What are you current presenting health concerns?
How long has this been bothering you?
Are you currently working with a health profession for treatment? If yes please include details
If yes, how long for?
Have you experienced any improvement in your symptoms?
Are there any past medical conditions (i.e. illness, trauma, addictions, excessive stress, anything else you feel is relevant) that could help me best understand your health and wellbeing and create a plan for you?

Family health history

	myself	mother	father	sister(s)	brother(s)	children	spouse	other
Age (if still living)
Age (if passed away)
Cause of death
Anaemia
Cancer
Diabetes
Epilepsy
Glaucoma
Hay fever
Heart disease
High blood pressure
Hives/allergies
Kidney disease
Mental illness
Obesity
Rheumatoid Arthritis
Stroke
Substance abuse
Tuberculosis
Other

Please use this space to give details about anything you have ticked above....
How would you describe your health during childhood?

How many glasses of water do you drink a day?
What do you typically eat for breakfast/in the morning?
What do you typically eat for lunch/in the afternoon?
What do you typically eat for dinner/in the evening?
When is your biggest meal of the day?
Describe your habits while eating? (do you generally eat at a table, sat down, standing up/on the go, do you have the TV on, do you eat quickly)
Are you currently prescribed any medication or herbs? Please list
Are there certain tastes you crave - sweet, salty, bitter, hot/spicy, oily?
Do you eat between meals? What do you usually snack on?
Are you hungry upon waking?
How do you feel after eating? (bloated, sluggish, heartburn, gas/beltching, fatigue)

Movement
Do you travel frequently? Please describe
Do you have a commute? How often? How long is your commute?
What sort of exercise/movement practices do you participate in?
How long do you exercise for each time?
How often do you exercise?
Rate the intensity of your exercise
Is there anything else you would like to share about your diet and exercise routines?

Daily Routines
How would you describe your daily routines most days?
Is it different to your ideal routine?
What time do you get up in the morning? Is it the same time every morning?
How do you feel when you wake up in the morning i.e. tired, well rested etc?

Sleep
How would you describe your quality of sleep?
Do you wake up frequently, experience nightmares, have trouble falling asleep?
Do you nap in the day?
What time do you go to bed? Is it the same time every night?
Is there anything else you would like to share about your sleep?
What does your evening look like a few hours before you go to bed?

Relationships
Current relationship status or most recent relationship
If you are currently in a relationship, how would you describe it?
How would you describe your past intimate relationships?
At what age did you first become sexually active?
Are you sexually active now (with or without a partner)?
What would you state is the past and present state of your sensual health?
Are you satisfied with your sex life? What would you like to be different?

Birth Control
Are you using any form or method of contraception?
Are you using or have you ever used hormonal contraceptives like the pill, patch, IUD or other?
Have you experienced any side effects from using the above methods of contraception?

Pregnancy
Are you or have you ever been pregnant?
Number of times you have been pregnant
Have you ever miscarried?
Have you ever experienced any complications during pregnancy, delivery or after giving birth? Please describe

The Mind
Sit for a moment and notice the rhythm of your breathing...allow thoughts to arise....what themes do you notice?
Has anyone in your family ever been diagnosed with mental illness?
Have you ever been treated for, diagnosed with or experienced symptoms of mental illness?

Current emotional experience

	Intensity	Frequency	Precipitating event (if known)
Anxious
Overwhelmed
Self-destructive
Resentment
Anger
Depressed
Intense
Melancholy
Stubborn
Irritated
Lonely
Fear/panic
High level of stress
Other

Please use this space to describe anything you have mentioned above
How well do you believe you handle stress?
What are some of the ways you manage stress right now?
Have you ever been addicted to any substances? What and for how long?

Work and Life
Do you currently work? What kind of work?
Do you enjoy the work you do?
How would you describe your typical schedule of major activities during the week? (work, children, school, caring)
Do you have hobbies you enjoy?
How often do you get to do them?
What are you most passionate about?

That is the end of the questions.

Thank you so much for your honesty, I do appreciate how personal some of the questions are but I can assure you this information will be kept in the strictest confidence.

I look forward to discussing your wellbeing further wih you soon and creating a journey plan to help you realign to balance.

Much love,

Holly x
Should be Empty:

	Never	once a week	multiple times per week	daily	Other
Carbs (bread, pasta)
Vegetables
Meat
Fruits
Dairy products
Alcohol
Coffee
Tea
Fizzy drinks (inc diet and water)
Sugar
Cigarettes/vape/chewing tobacco
Recreational drugs