TWWC Client Intake Form

TWWC Client Agreement Intake Form

Standard wellness coaching and consulting intake form. Complete all fields that apply.
Confidentiality & Privacy Policy

Thrive Workforce Wellness & Consulting, LLC collects, uses, and protects personal information shared during wellness coaching, workshops, trainings, and related non medical services. Because the Company does not provide medical care or clinical services, it is not a HIPAA covered entity. However, the Company is committed to maintaining a high standard of privacy and confidentiality for all clients and participants. Please see our Confidentiality & Privacy Policy for more details.
Category

Other
Organization Details

If you're an Organization, please provide your business information, then proceed to wellness assessment.
Organization Name
Business Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Contact Person

First NameLast Name
Business Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Number of Employees
Service (s) Required
Individual Client

General Information
Full Name

First NameLast Name
Age
Preferred Pronouns
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
City/State/Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
If Other Category, please specify
Preferred Contact Method
Emergency Contact and Health History
Emergency Contact Name

First NameLast Name
Emergency Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Current wellness concerns you would like support with
Physical limitations or restrictions coach should be aware of
Do you have any allergies?
If yes, please specify allergies
Have you been encouraged by a healthcare provider to make lifestyle changes?
If yes, describe in general terms
Current medications or supplements (Optional)
Wellness Assessment
Overall well-being
Days per week of physical activity
Type of physical activity
Eating habits
Hours of sleep per night
Stress level
Main sources of stress
Goals, Motivation, and Work/Lifestyle Context
Primary wellness goals

Other
If other wellness goal, please specify
What motivated you to seek wellness coaching?
What challenges have prevented you from reaching your goals?
Commitment to making lifestyle changes
Do you experience work-related or group-related stress or burnout?
Hours you work or participate weekly
Do you sit for long periods during work or activities?
Interested in workplace or group wellness support
Cultural, personal, or faith-based values your coach should be aware of
Agreement and Signatures
Client Name
Client Signature
Client Date

MonthDayYear
Date
Guardian Name (if client is under 18)
Guardian Signature
Guardian Date

MonthDayYear
Date
Coach Signature
Coach Date

MonthDayYear
Date
Should be Empty:

TWWC Client Agreement Intake Form

Confidentiality & Privacy Policy

Organization Details

Individual Client

Emergency Contact and Health History

Wellness Assessment

Goals, Motivation, and Work/Lifestyle Context

Agreement and Signatures