Wellness Coaching Intake

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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

Rows	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

Rows	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

Rows	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

Rows	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

Rows	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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