Confident Health GPS Intensive Intake Form

The Confident Health GPS Intensive Intake Form

Thank you for completing this intake form before your session. Your responses will help us make the most of our time together and create a personalized, realistic plan that supports your body and mind. Please complete this form at least 24 hours before your session.
Basic Information
Name

First NameLast Name
Age
Email
example@example.com
Marital Status
Occupation
Your Current Season of Life
Briefly describe your current season of life.Examples: caregiving responsibilities, work stress, parenting, health challenges, schedule demands, major life changes, etc.
What are the 5 most important things in your life?
What made you decide to book the Confident Health GPS Intensive right now?
Your Health Goals
What are your top 3 health or wellness goals right now?
Your Current Challenges
What health “shoulds” have been weighing on you lately? Examples: things you feel like you should be doing but struggle to follow through on.
What do you feel keeps getting in the way?
Medical & Health Background
Do you have any current health concerns, diagnoses, or symptoms you would like me to be aware of?
Are you currently working with any healthcare providers or specialists? If yes, please specify.
Are you currently taking any medications or supplements? If yes, then please indicate the medication name and the purpose below:
Do you have recent lab work, provider recommendations, or health reports you would like to review during our session?
Please upload any reports here (do not send sensitive health information via email)

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Nutrition, Movement & Lifestyle
How would you currently describe your eating habits?
How would you currently describe your movement or exercise routine?
How would you describe your current sleep and stress levels?
What healthy habits have worked well for you in the past?
Motivation & Vision
Why is improving your health important to you right now?
If nothing changed over the next year, how would that feel?
If you could create a healthier, more supported lifestyle, what would become possible for you?
What personal strengths do you already have that could support your health goals?
Preparing for your Session
What are you hoping to walk away with from this Intensive?
Is there anything else you would like me to know before we meet?
Sessions may be recorded and transcribed to support coaching, reflection, and session notes. I may use anonymized excerpts or summaries to support my coaching process. All materials are kept confidential and are not shared publicly.
AGREEMENT/REMINDERS:

I understand that the information shared in this form will be kept confidential and used only to personalize my coaching and consulting experience.

I understand that the Confident Health GPS Intensive is designed to provide education, guidance, clarity, and behavior change support. It does not diagnose, treat, or replace medical care from a licensed healthcare provider.

I understand that this process is collaborative, and my results will depend on my participation, honesty, and follow-through.
How did you find out about our services?

Other
Would you like to subscribe to my email list?
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The Confident Health GPS Intensive Intake Form

Basic Information

Your Current Season of Life

Your Health Goals

Your Current Challenges

Medical & Health Background

Nutrition, Movement & Lifestyle

Motivation & Vision

Preparing for your Session