Wellness Coaching – Client Intake Form 🌿
Share your goals, current challenges, and preferences so I can support you effectively—please skip medical diagnoses, medications, or health history.
Section 1 – The Basics
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Time Zone
Preferred Pronouns
How did you hear about me?
Social Media
Upwork
Referral
Other
Section 2 – Your Current Reality
What is the #1 challenge you want support with right now?
*
How much does this affect your daily life, energy, or peace of mind?
*
Barely bothers me
1
2
3
4
5
6
7
8
9
Consumes me
10
1 is Barely bothers me, 10 is Consumes me
How long have you been dealing with this?
*
Less than a month
1-6 months
6 months - 1 year
1-3 years
3+ years
What wellness practices, routines, books, or coaching have you already tried?
Section 3 – Your Wellness Snapshot (Mind, Lifestyle, Energy)
Mind and emotions: how would you describe your mental and emotional state most days?
*
Overwhelmed / anxious
Depleted / exhausted
Foggy / unfocused
Hopeful but stuck
Generally stable
Other
Daily habits: how would you describe your current sleep, movement, nutrition, and stress-management routines?
Which areas would you most like to improve?
*
Sleep routine
Daily energy
Stress management
Movement and exercise
Nutrition habits
Work-life balance
Mindset and motivation
Other
Energy and purpose: how connected do you feel to your sense of purpose or inner knowing right now?
*
Completely disconnected
Faintly aware but ignoring it
Curious but uncertain
Connected and aligned
Other
Section 4 – Your Vision and Goals
Imagine it’s 6 months from now and this challenge is resolved. What does your life look like? Please describe how you feel, what you’re doing, and who you’re with.
*
What specific, measurable outcome would make this a success for you?
*
How ready are you to make changes right now?
*
Just browsing
1
2
3
4
5
6
7
8
9
I'll do whatever it takes
10
1 is Just browsing, 10 is I'll do whatever it takes
Section 5 – Logistics and Preferences
How would you like me to follow up with you?
*
Email
Text
Zoom video call
Phone call
Flexible / any
When are you available for a 30-minute discovery call? Please share your preferred days and times.
*
Is there anything else you'd like me to know about your goals or situation? Please do not include medical information.
Section 6 – Agreement and Next Steps
I acknowledge and agree
*
I understand this is a wellness coaching service. Coaching is not medical care, and it doesn't diagnose, treat, or replace advice from a licensed healthcare provider.
I acknowledge and agree
*
I understand I'm responsible for my own well-being and decisions.
I acknowledge and agree
*
I understand I should not share medical diagnoses, medications, or treatment details in this form.
I acknowledge and agree
*
I understand my information will be kept confidential and used only for coaching purposes.
Signature (type your full name)
*
First Name
Middle Name
Last Name
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit Intake
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