Wellness Coaching Intake

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example@example.com
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Relationship Status
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Wellness Self Assessment

There are many components of overall wellness. Please reflect on the statements below and answer accordingly. 1 = never / no ; 2 = rarely / seldom ; 3 = sometimes / often ; 4= usually / always

EMOTIONAL HEALTH & RELATIONSHIPS

	1	2	3	4
I find healthy ways to cope with stress (e.g. exercise, meditation, social support, self-care activities, etc.)
I am able to ask for assistance when I need it, either from friends and family, or professionals.
I am able to set and follow through on my priorities.
I feel good spending time alone with myself.
I am flexible and able to adapt/adjust to life’s changes in a positive way.
I can express all ranges of feelings (i.e. hurt, sadness, fear, anger, joy, etc.) and manage emotion-related behaviors in a healthy way.
I maintain a balance of work, friends, family, and other obligations.
I feel connected to myself and my emotions.

MINDSET & SPIRIT

	1	2	3	4
I take time to think about what is important in life – who I am, what I value, where I fit in, where I’m going.
I make time for relaxation during the day.
I have a belief system in place (religious, agnostic, atheist, spiritual, etc.).
My values guide my decisions and actions.
I have a sense of purpose in my life.
I am tolerant and accepting of the view of others.
I utilize resources to improve my well-being.
I am able to set, communicate, and enforce boundaries.

MOVEMENT & NUTRITION

	1	2	3	4
I manage my weight in healthy ways.
I enjoy moving in my body.
I spend time outdoors enjoying nature.
I maintain healthy eating patterns.
I stay hydrated and drink water throughout the day.
I eat nutritious food.
I have good digestion.
I sleep well and feel rested upon waking.

LIVELIHOOD & PURPOSE

	1	2	3	4
I am able to balance work, play, and other aspects of my life.
I take advantage of opportunities to learn new things.
I follow my curiosity.
I enjoy how I make my livlihood.
I know my own value.
I feel good about the future.
My home life is safe and comfortable.
I look for ways to express my creativity and critical thinking skills.

SOCIAL LIFE & COMMUNITY

	1	2	3	4
I am satisfied with my social life.
I have at least one meaningful relationship in my life.
I am able to prioritize my own needs by saying “no” to others’ requests for my time.
I plan time with my family and friends.
I feel connected to others in my community.
I feel supported.
I am happy with myself and others.
I have balanced and satisfying relationships.

Do you have any current physical, mental or emotional health challenge?
What are your desired outcomes for Wellness Coaching? *
Anything else you'd like me to know?
Thanks for taking the time to fill this out before we meet. This information will help build a foundation for where we start this journey together.

I look forward to seeing you soon, Regina / Regi
What inspires you to seek Wellness Coaching with Regina?
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