Health & Wellness Needs Assessment

Name

First NameLast Name

Gender

Age

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Preferred method of contact

Do you currently have any of the following health conditions?

How long have you been experiencing these issues?

Are you currently taking any medications / supplements? If yes, please list.

Do you have any allergies or dietary restrictions? If yes, please list.

Rate your overall wellbeing right now.

Have you worked with a health coach before?

What are your top 3 health goals?

On a scale of 1-5, how committed are you to taking control of your health?

1 is 0%, 5 is 100%

What is one thing that may be holding you back from reaching your health goals?

How did you hear about my services?

CONFIDENTIALITY ACKNOWLEDGMENT:

I understand that all information provided in this intake form is private and confidential.

The data gathered from this form will only be used by Dani Morgan - Holistic Health Coach, for the pupose of assessing my current wellness needs and creating a personalized coaching plan to help me reach my goals. The information collected will not be shared with third parties without prior consent.

PERSONAL RESPONSBILITY / COACHING COMMITMENT AGREEMENT:

I understand that in order to be successful in this wellness journey, it is vital to follow the plan agreed upon by both the wellness coach and myself. I recognize that my health and life are ultimately my responsibility and no one else can do the work for me. I alone, have the power to create meaningful change in my life through my daily choices.

I agree to participate in this coaching relationship with openness, honesty, and willingness. I understand that this coaching is a collaborative process and that any recommendations made are not medical diagnosies, but holistic wellness suggestions.

I have read and agree to the Confidentiality Acknowledgement and Personal Responsibility / Coaching Agreement.

Signature

Health & Wellness Needs Assessment

BASIC INFORMATION

CURRENT HEALTH & WELLNESS

GOALS / INTENTIONS