Gorgeous Within Wellness Intake
Complete this form to help us understand your goals, current wellness, and how we can best support your journey.
Full Name
First Name
Last Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Intake
-
Month
-
Day
Year
Date
What inspired you to begin coaching now?
How do you want to feel in your body and life?
What would success look like in 3–6 months?
Current Wellness Snapshot
Tell us about your current habits and health.
Energy level (1–10)
Low
1
2
3
4
5
6
7
8
9
High
10
1 is Low, 10 is High
Average hours of sleep per night
Stress level (1–10)
Low
1
2
3
4
5
6
7
8
9
High
10
1 is Low, 10 is High
How often do you exercise?
Please Select
Never
1–2 times/week
3–4 times/week
5+ times/week
Other
How much water do you drink daily?
Please Select
Less than 1 liter
1–2 liters
2–3 liters
More than 3 liters
Not sure
Current health concerns (if any)
Medications and/or supplements/peptites (if any)
Nutrition
Share your current eating habits and challenges.
How would you describe your relationship with food?
What is your biggest nutrition challenge right now?
Do you have any dietary restrictions?
Emotional Wellbeing
Help us understand your emotional wellness.
What are your main stressors?
How do you currently cope with stress?
What support helps you most? (Select all that apply)
Accountability
Structure
Encouragement
Education
Other
Goals
Set your intentions for the next 3–6 months.
List your top 3 goals
On a scale of 1–10, how ready are you to commit to change?
Not ready
1
2
3
4
5
6
7
8
9
Very ready
10
1 is Not ready, 10 is Very ready
Signature (please sign below)
Submit Intake Form
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