Wellness Coaching Intake Form

Wellness Coaching Intake Form
Name

First NameLast Name
Age
Date of Birth

MonthDayYear
Date
Phone Number
Format: (000) 000-0000.
Email
example@example.com
Service Wanted
What are your personal goals?
What are your expectations from this coaching relationship?
Preferred Time Slot
My Wellness Services
prevnext( X )
Empowered Beginnings
1:1 Mindset Coaching *$50 per additional hr*

$75.00



We’re Invested in US
Holistic Relationship Coaching (1 hr Sessions) * $50 per additional hr.

$70.00



Dance Fitness
Prices are for 6 Week Programs .

$80.00



Personalized Package
A Personalized Plan designed to merge Mindset Coaching and Dance Fitness. Final price will be discussed between client and coach. * 6 weeks minimum *

Free



Total

$0.00
Goddess Code
Payment Method
Payment Instructions will be sent following form submission ; followed by appointment confirmation and Zoom or meet up instructions
How did you find out about our services?
AGREEMENT/REMINDERS:

I understand that all information I entered in this form will be considered strictly confidential.

The data gathered from this form will only be used as a basis for the type of coaching the client will need.

I understand that in order to be successful, it is vital to follow the plan and be consistent agreed by both the wellness coach and the client.
Signature
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