Soul Centered Strength Intake Form
The Basics
Name
*
First Name
Last Name
Date
*
/
Month
/
Day
Year
Today's Date
Birthday
*
/
Month
/
Day
Year
Birth Date
Email
*
example@example.com
Cell Phone #
*
Please enter a valid phone number.
Format: (000) 000-0000.
Sex
*
Divine Masculine
Divine Feminine
Other
Height (Feet, Inches)
*
Weight (please step on the scale naked, not a guesstimate)
*
Back
Next
Current Picture
Help me have a better understanding of what's going on in your world so I can best coach you
Why are you hiring me as your coach?
What would you like to accomplish in our coaching?
*
Please explain in detail why this is important to you.
*
What obstacles have stopped you from achieving your health and wellness goals in the past?
*
How committed are you to accomplishing your goals? On a scale of 1-10, how committed are you to accomplishing your goals?
*
Not really
1
2
3
4
5
6
7
8
9
I'll do whatever it takes
10
1 is Not really, 10 is I'll do whatever it takes
My current body most closely resembles (please select one)
*
Ectomorph - I have a skinny appearance. I'm often below average weight for my height and often complain of relentless eating with little to no weight gain.
Endomorph - I am larger in appearance. I tend to accumulate fat far easier than muscle, and find it very difficult to lose weight even though I've tried several diets.
Mesomorph - I have a large frame with very low body fat percentage. I tend to put muscle on easily, burn fat easily and have a symmetrical build with wide shoulders.
Are you currently engaged in daily physical activity?
*
Yes
No
If Yes, please describe (duration, activity, frequency, etc.)
What activities/sports have you engaged in throughout your life?
*
Please list any and all injuries and surgeries you have received throughout your life and the dates associated with each.
*
Please tell me about any relevant physical and mental health conditions you have had and/or currently have?
Are you currently taking any medications? Please list all.
What strength and movement experience do you have? Check all that apply.
Zero experience, I'm a rookie.
A little bit but not really sure what I'm doing most of the time.
I've worked with a personal strength coach before.
Competitive athlete and am comfortable in the gym.
Which type of progress is most important to you?
*
Immediate progress that’s less easily maintained.
Maintainable progress that may not be as rapid.
On average, how much time are you willing to prioritize per day towards your exercise and movement program?
*
30 Minutes or Less
30-60 Minutes
60-120 Minutes
120 Minutes +
How many days a week are you willing to dedicate towards your training/movement program?
2x/week
3x/week
4x/week
5x/week
6-7x/week
What type of access to exercise equipment do you have?
*
None - just my body.
I belong to a gym.
I have a few 5 lb dumbbell's in my home somewhere.
Other
Please list the equipment you have at your disposal.
Are you seeking In person coaching (Kirkland, WA) or distance online training?
*
In-Person
Online
Both
Do you practice meditation?
Daily
No
Infrequently
Please share, in detail, about your relationship to meditation and/or breathing practice.
Please tell me about your relationship with yourself. Are you your own harshest critic? How do you show yourself love? Do you mostly have positive self talk or negative self talk?
Do you experience chronic pain/achiness in your body? If yes, please describe where and how your experience your pain (ie - tense, achy, dull, hot, numbness, tingling, cold, etc.)
*
When stressed, how do you cope? Pick as many that apply to you. - Get real with me - It's all love.
*
Cry
Scream
Eat
Smoke
Drink
Pop a pill
Fight
Zone out
Go on a walk
Exercise
Take a bath
Meditate
Breathe
Sex (with others or self)
Other
Back
Next
Food
You can't out train a poor diet
Current diet/eating style?
*
I ain't picky!
Vegan
Vegetarian
Pescatarian
Paleo/Primal
Opportunivore
Other
Please explain your definition of “healthy eating.” – Be as specific as possible.
Explain your biggest perceived issue with food.
Example: I’m too busy, I’m an emotional eater, I’m a stress eater, I binge eat, I don’t know WHAT or how much to eat, etc…
How many times a day do you usually eat?
Please list an average day of food consumption for you – including time of day and serving size. Be as specific as possible.
How many ounces of water do you usually drink per day?
Do you drink caffeine? If yes, how much per day?
Have you ever tried any popular diets? If yes, which ones and for how long?
*
If yes to the above question - what worked for you and why?
Are you currently taking any supplements? Please list them and why.
*
How much time each week are you willing to meal prep your food in advance?
60 minutes or less
60-120 minutes
It doesn't matter, I'm committed to making this happen.
I hate meal prepping and refuse to. (If this is your answer...good luck to you.)
What's your relationship with alcohol like? Go into detail. Do you drink daily? How much per week? What do you like to drink? Etc.
Do you use recreational drugs? If so, what kind and how often? (No judgment. - It's all love.)
Back
Next
Life, Etc.
All this info is important.
What brings you joy in your life?
*
Describe a period in your life where you felt most fulfilled and happy with yourself and your life?
Please tell me about your childhood relationship with your parents and family. (Go into as much detail as you would like please. If not comfortable, it's all good. I like to know where you're coming from and prescribe exercises that might help deal with trauma/tension, etc.)
Please tell me about your current family/friend situation? Married with kids? Lonely? Happily single? Divorced/separated? Dating? All of the above?
What's your current relationship like with your siblings and parents?
What stresses you out the most on a regular basis?
Tell me about your sleep. On average, what time do you go to bed? How many hours do you sleep a night? Deep or light sleeper? D you wake up in the middle of the night? What position do you prefer to sleep in? Do you take naps?
*
How's your overall energy from day to day?
*
I'm a zombie.
1
2
3
4
I feel awesome, pretty consistently.
5
1 is I'm a zombie., 5 is I feel awesome, pretty consistently.
What do you do for work?
*
How many hours per day do you "work"? Swing shift? 9-5? Go into detail.
Are you seated most of the day? How many hours do you on average spend sitting?
How much INTENTIONAL time a day on average do you spend outside?
What do you feel like you need the most from me as a coach to help you succeed?
Back
Next
Spiritual/ Values
Help me understand what you value.
What thoughts/feelings/emotions are conjured up for you when you hear the word "spiritual"?
What values are important to you that you try to honor and live by?
Do you consider yourself a spiritual person?
No way, Jose.
Kinda.
I'm spiritual AF.
In regards to the last question, please go into further detail.
Do you have any desire to cultivate a deeper relationship with your soul/spirit?
Yes & Amen!
Naaah, I'm good.
I'm interested but not sure.
In regards to the last question, please explain.
Submit
Should be Empty: