Nzuri Transformational Group Coaching

Nzuri Transformational Group Coaching

INTAKE FORM
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Holistic Wellness Assessment

This overview of your current situation will provide a basis on which to structure your holistic wellness programme. Please answer each question to the best of your ability, as truthfully and comprehensively as possible. We will track your progress over the course of our coaching relationship as we aim for continuous improvement and transformation!
Imagine that you have access to all the resources and support you need to create your ideal life. Close your eyes, take some deep breaths and visualise what it looks like...how it feels. What do you see? What do you smell? How do you feel? What is surrounding you? Who are you with? Describe what a day in your "Rich Life" looks like.*
Think BIG! Do not temper your thoughts.
Where do you see yourself 10 years from now...5 years from now...1 year from now...six months from now...one month from now? We will use this to compare your results to your benchmarks...without judgement. Be expressive and expansive with your plans. And remember, you are always exactly where you are supposed to be!*
Again, anything is possible. Do not limit yourself.
What are the broad steps you need to take to achieve your six-month goals?*
According to the Seven Pillars of Wellness
I) SPIRITUAL

Spiritual wellness helps you to feel connected to a greater source and understand the purpose and meaning in your life. It also provides a grounding force that allows more graceful and peaceful management of the challenges and stresses you encounter. Spiritual practices include the things that you can do to enrich your soul, balance your emotions and heal, such as prayer, meditation, journalling, gratitude, breath work, fasting and spending time in nature.

Please rate your level of satisfaction with your spiritual wellness.*

	1	2	3	4	5	6	7	8	9	10

1 is Low, 10 is High

What are your spiritual practices? How often do you engage in these practices on a daily or weekly basis?*
What do you think you need to do to improve your spiritual wellness?*
Be very specific.
II) PHYSICAL

Physical wellness can be defined as a strong, healthy body that has the energy necessary to effectively support your daily activities. While all wellness pillars are interconnected, the most important inputs for physical wellness are a nutrient rich, well balanced diet, regular exercise, sufficient water intake and getting enough rest.

Please rate your level of satisfaction with your physical condition.*

	1	2	3	4	5	6	7	8	9	10

1 is Low, 10 is High

Please indicate the type of exercise you are currently engaging in.*

	Type/Intensity (low/mod/high)	# Days/Week	Duration (mins)	Provide Additional Details
Stretching/Yoga
Cardio/Aerobics
Walking/Jogging
Strength Training
Martial Arts
Sports, Dance or Leisure
Swimming
Other

Is there anything that is not included in the table above that you consider exercise?*
Please provide details of activity, intensity, frequency and duration.
Is this sufficient or would you like to do more? Ideally, how much would you engage in these physical activities on a weekly basis?*
Be brutally honest with yourself. Remember what your ideal life looks like.
Are there any problems that limit your physical activity?*
How many hours of sleep do you typically get every night? Do you think that you get enough - do you feel refreshed when you rise in the morning?*
How would you rate the overall quality of your sleep? (0-low, 5-high)*
What is your usual energy level? (0-low, 5-high)*
Are you comfortable with your current weight? If not, what do you need to do to get to your ideal weight?*
Please be specific - e.g. how much weight do you want to lose or gain?
III) NUTRITIONAL

You should aim for a well balanced, nutrient rich diet that includes as many fresh, naturally grown, whole (unprocessed) foods as possible with lots of in season fruits and vegetables and whole grains. Your daily food intake should be appropriate for your height and body type and should include foods from several food groups. You should be mindful of any food restrictions, limitations and sensitivities that you have.

Please rate your satisfaction with your nutritional wellness.*

	1	2	3	4	5	6	7	8	9	10

1 is Low, 10 is High

Check all that apply to your current eating habits:*

Fast eaterStruggle with eatingNegative relationship with foodLove to eat"Eat because I have to" issuesErratic eating patternsEmotional eaterEat too much/overeatEat fast food frequentlyLate night eatingOnly like to cook for othersUnclear about what good nutrition isTime constraints prevent proper mealsDislike "healthy food"Rely heavily on quick mealsPoor snack choicesLove snackingDo not plan mealsEat three proper meals a dayEat lots of fruit and veggiesVeganVegetarian with fishVegetarian without fishMacrobioticOrganicLocal foods onlyRaw foodsGluten FreeGluten/Casein FreeOther
What are your nutritional wellness goals? What do you need to do to achieve them?*
Please note any additional comments about your nutrition/eating habits:*

In order to improve your health and wellness, how willing are you to: (Rate on scale of 1-not willing to 5-very willing)*

	1	2	3	4	5
Significantly modify your diet (over time)
Keep a record of everything you eat each day
Modify your lifestyle (work demands, sleep habits, exercise)

IV) MENTAL/EMOTIONAL

Mental wellbeing is determined by your capacity for processing information and experiences and is characterised by your thoughts, feelings and behaviours, while emotional wellness is how you understand and manage your feelings. Many factors can have a positive or negative impact on your mental/emotional wellbeing, including your home and work environments, your finances, your relationships, your upbringing, illness, loss and daily stresses. It is important to be able to manage your responses to any negative factors through various remedies, coping mechanisms and daily self care rituals.

Please rate your level of satisfaction with your general mental/emotional state.*

	1	2	3	4	5	6	7	8	9	10

1 is Low, 10 is High

What is your ideal mental/emotional state?*
You don't have to think that this is realistic. It is your ideal state.
What triggers mental or emotional anguish for you?*
List as many as you can think of.
How do you currently manage the stresses in your life?*
What makes you feel good? How often do you do these things?*
V) LIFESTYLE

Your lifestyle is a combination of your daily routines, your social interactions (e.g. with family and friends), your choice and frequency of entertainment, your engagement with the environment, your relationship with education, interests/hobbies and self care practices.

Please rate your overall level of satisfaction with your lifestyle*

	1	2	3	4	5	6	7	8	9	10

1 is Low, 10 is High

What type of lifestyle would you like to have?*
Again, do not limit yourself to what you think is "realistic". Reach for the stars!
What are your current self care practices?*
How can you improve your lifestyle? Are you willing and able to do these things?*
VI) LIVELIHOOD/CAREER

Livelihood/career is how you make a living or your current occupation. This considers all sources of income that you are generating (actively and/or passively) and whether they are enough to meet your needs. Wellness in this pillar speaks to how fulfilled you are, including whether you are being enriched and can utilise your knowledge, skills and talents in a way that satisfies your ambitions and personal values.

Please rate your overall level of satisfaction with your livelihood/career.*

	1	2	3	4	5	6	7	8	9	10

1 is Low, 10 is High

How much do you agree with the following statements: (Rate on scale of 1-strongly disagree to 5-strongly agree)*

	1	2	3	4	5
I am happy with my choice of career/how I earn a living.
I look forward to getting up in the morning to do this work.
My work responsibilities and duties are consistent with my ethics and values.
My work satisfies and stimulates me.
I am happy and content with the personal and professional opportunities for growth and development.
My income is sufficient to cover all my needs and the needs of those for whom I am responsible.
When I am working in my profession, I do not experience high levels of stress.
My work allows me to make a difference in my community.

If your overall level of satisfaction with your livelihood/career is below 8 or 9 and most of your responses to the above statements are 3 or below, what else would you prefer to do? Have you started working on it already?*
Do you want to transition fully from what you are currently doing? If yes, within what timeframe do you want this to happen? How possible is this?*
How much would you like to earn per year?*
No limits!! In fact...when a particular amount comes to mind, double it!
How can you achieve this income goal?*
Make a note of all the ways you can earn income in ways that appeal to you. What are you passionate about?
VII) FINANCIAL WELLNESS

Financial wellness includes how well your income covers your needs and wants, how well you plan for and manage your finances responsibly to ensure that your future needs are covered, making informed financial decisions and minimising debt.

Please rate your overall level of satisfaction with the way you manage your finances.*

	1	2	3	4	5	6	7	8	9	10

1 is Low, 10 is High

Do you maintain a monthly budget and reconcile your actual income and expenditures against your budget? Has this made a difference in the way you manage your money?*
Are you living within your means (income > expenditure) or above your means (expenditure > income)?*
Are you planning for future expenditures including retirement? How well do you think you are doing?*
What do you think would make the greatest difference in your quest for financial wellness?*
Confidentiality and Non-Disclosure

NOTICE OF PRIVACY PRACTICES
The privacy of the information you provide to Nzuri Holistic Wellness is important to us. We understand that this information is personal and we are committed to protecting it. We will maintain a record of the information you provide, our coaching sessions and any other services you receive from Nzuri Holistic Wellness. We need this record to provide you with quality service and to ensure that you get the most from this experience.

We will not use or disclose your information for any purpose without your specific written authorisation. Any specific written authorisation you provide may be revoked at any time in writing.

Nzuri Holistic Wellness
Confirmation

I have reviewed the Notice of Privacy Practices and I have been provided an opportunity to review it. I acknowledge and agree that by inputting my full name in the box below, I am delivering a digital signature that shall be viewed as an original manual paper signature.
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Informed Consent

UNDERSTANDING MY RESPONSIBILITIES
I am solely responsible for my decision to work with Leah Clarke, Holistic Wellness Coach, and Louise Sam, Holistic Practitioner, who will provide Holistic Wellness Coaching services. I recognise that some recommendations may not prove to be successful. I understand some recommendations may be novel. I agree to participate in an active manner, monitor my progress, and report any concerns immediately to Leah Clarke and/or Louise Sam.

I also understand that a coach is not a medical practitioner or psychologist and any critical or life threatening physical, medical or psychological problems will be referred to the appropriate trained professional. It is recommended that I discuss the use of any suggested treatments or courses of action with the appropriate trained practitioner before implementing.
Confirmation

To the best of my knowledge, I confirm that the information in this form is accurate. I acknowledge and agree that by inputting my full name in the box below, I am delivering a digital signature that shall be viewed as an original manual paper signature once I click on the 'Submit' button below.
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Nzuri Transformational Group Coaching

Holistic Wellness Assessment

According to the Seven Pillars of Wellness

Confidentiality and Non-Disclosure

Informed Consent