Ready to book in for Omm & Thrive Coaching?
Complete this form and I’ll get back to you so we can get it in the diary.
What's your name? Please provide your first and last name.
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Date of birth
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Day
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Month
Year
Date
Gender Identity
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Male
Female
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Address
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Street Address
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City
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What's your email?
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Phone Number
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Do you have any medical conditions or health concerns?
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Yes
No
If ''yes'', please give more details.
In case of an emergency, who should I contact? Please provide their name, relationship to you, and phone number.
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Please provide the name and contact details of your GP surgery.
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Do you have or have you ever had an eating disorder?
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Yes
No
If ''yes'', please give more details.
Are you currently on any medications or supplements?
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Yes
No
If ''yes'', please give more details.
Are you having any problems with your quality of sleep?
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Yes
No
Sometimes
How would you rate your energy levels throughout the day? (Low, Moderate, High)
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Low
Moderate
High
Do you feel refreshed when you wake up in the morning?
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Yes
No
How would you describe your current stress levels?
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Low
Modetate
High
How do you typically cope with stress? (e.g., exercise, talking to someone, food, etc.)
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Do you experience anxiety, depression, or other mental health challenges?
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Often
Sometimes
Rarely
Never
On a scale of 1 to 10, how would you rate your overall mental well-being at the moment?
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How active are you on a daily basis? (Sedentary, Lightly Active, Very Active)
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Sedentary
Lightly active
Active
Very active
Do you engage in self-care activities?
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Every day
Once a week
Once or twice a month
What is self-care?
Do you enjoy cooking?
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Yes, I enjoy experimenting with new recipes
Yes, but I prefer simple, quick meals
It’s okay, but not my favorite activity
No, I find it stressful or time-consuming
Do you practice or observe a religion?
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Yes
No
If yes, what is your faith?
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Do you consider yourself to be spiritual?
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Yes
No
What areas would you like to focus on during our coaching sessions (e.g., food-related issues (binging, emotional eating), stress, sleep, physical health, emotional wellbeing, mindset, etc.)?
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How supportive are the people around you (family, friends, work) when it comes to your goals?
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On a scale from 1 to 10, how motivated do you feel right now to make changes to achieve your goals?
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Have you ever worked with a counsellor, coach or wellness professional before?
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Yes
No
Is there anything else that you would like to mention?
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Where did you hear about me?
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