Initial Wellness Intake Form

504 Coaching Program initial form

Agreements + Intake
This short form helps us gather the essentials about your current health, lifestyle, and goals before scheduling your first virtual consultation.

Our team uses this initial information to prepare your basic wellness strategy while deeper assessments (labs, composition analysis, or referrals) may be discussed during follow up.

Think of this as the first step toward a more personalized approach to nutrition, body composition, and long-term health.

Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Email*
example@example.com
Date of Birth

MonthDayYear
Date
Tell us a bit more about yourself

(These questions help us get to know you better before your first virtual consultation. Feel free to answer open question in your own words.)
1 - What motivated you to seek guidance in health, nutrition, or wellness at this time?
2 - What goals would you like to achieve—physically, mentally, or in your lifestyle?
3 - Have you tried other methods or programs before? What was your experience like?
4 - Is there anything important you think we should know about your health, lifestyle, or routine?

CLIENT AGREEMENTS

I confirm that the information provided in this form is true and complete to the best of my knowledge. I understand that this form is intended for informational and preliminary purposes only and does not constitute a medical diagnosis or treatment plan.
I authorize the 504 Coaching Program team to review my responses in order to prepare an initial strategy and schedule a personalized virtual consultation.
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504 Coaching Program initial form