CHC Interest Form

Providence Health Coaching

Complete this interest form to let us know you'd like more information on this 9-month program. A certified health coach will contact you to discuss and determine next steps.
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
City, State*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
What is your Time Zone?*
Which is your preferred weekday contact window?*
Our certified health coach will call you between these hours. This is a 15-minute call for next steps.
How did you hear about us?*
Who was your referring provider/clinic?*
Enter provider/clinic name and location (city, state)
Are you a Providence employee?*

YesNo
Optional Demographic Information

Would you consider helping us continue to offer, improve, and enhance our free community classes and programs? This demographic information will help us improve our ability to serve our participants, enhance funding, and perform research around healthy lifestyle behaviors and our community-centered programming. All research data will be de-identified. We do not sell or give your information to third parties.
Would you mind answering our demographic questions?*

Happy to answer!No thanks.
Age
Do you consider yourself to be Hispanic or Latino?
What race(s) do you consider yourself to be?

Alaska NativeAmerican IndianAsianBlack/African AmericanNative Hawaiian/Other Pacific IslanderWhite/CaucasianSome other racePrefer not to sayUnknown
How do you identify?

ManNon-binaryWomanPrefer to self-describe
PARTICIPANT WAIVER

Please read the information below and then check the box indicating your understanding.
By checking the box below, you understand the following: Thank you for participating in Health Coaching offered by Basecamp Prevention + Wellness, part of the Providence Heart Institute of Oregon. Your choice to participate certifies that you have no known ailment, disease, or organic condition, which would make your participation in these classes dangerous to your health and safety. Please stop participation in these classes if any changes in your health, mental or physical condition affects your ability to participate (pregnancy, injury, illness, etc.). Information shared during these classes is for informational purposes only and is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Your participation acknowledges: 1) You have consulted with or had the opportunity to consult with your physician concerning your participation in these classes, 2) You release Basecamp Prevention + Wellness, Providence Heart Institute, its agents, representatives, employees, volunteers and any sponsors of the classes from any and all damages, causes of action, claims and liability that might arise from your participation in these classes.
Participant Waiver Acknowledgment*

I understand.
The Providence Health Coaching program is currently available only to residents within the United States. We invite you to browse our website for resources to support you living your healthiest life.
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Providence Health Coaching

PARTICIPANT WAIVER