TMHA Wellness Coaching Intake Form

TMHA Wellness Coaching Intake Form
📋 Welcome!

Before your first wellness coaching session, we'd love to learn a little more about you. This form helps your coach prepare to support you in the best way possible.

Wellness coaching is a safe, confidential space to set goals, celebrate your strengths, and work through challenges — at your own pace, in your own way. There are no right or wrong answers here. Just be you. 🦋

This form should take about 5–10 minutes to complete.
SECTION 1: About You
Name

First NameLast Name
Preferred Name or Nickname (What do you like to be called?)
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Pronouns

Other
Butterfly Dreamz Office Location
Grade

Other
Date of Birth

MonthDayYear
Date
SECTION 2: How Are You Doing?

These questions help your coach understand where you're starting from. Be as honest as you feel comfortable.
Overall, how would you describe how you've been feeling lately?
What areas of your life would you most like support with? Select all that apply.

Other
On a scale of 1–5, how confident do you feel in your ability to reach your goals right now?
On a scale of 1–5, how supported do you feel by the people around you (friends, family, community)?
SECTION 3: Your Strengths & Goals

Wellness coaching is all about building on what's already inside you. Let's start there.
What are 2–3 things you're proud of about yourself — your strengths, values, or things you've overcome? These don't have to be big things. Maybe you're a great listener, you never give up, you're creative, you show up for your people — whatever comes to mind.
What is one thing you would like to work on or improve in the next 30 days? This is your 30-day goal. It can be big or small — anything from bringing up a grade to sleeping better to speaking up more at home.
Why does this goal matter to you? What would it mean for your life if you achieved it? There's no wrong answer — we just want to understand what's driving you.
What has gotten in the way of this goal in the past (if anything)? Barriers could be time, stress, other people, not knowing where to start, or anything else.
What does support look like for you? What helps you most when you're working toward something? For example: having someone check in on you, working step by step, talking things through out loud, having accountability, etc.
SECTION 4: Your Wellness Coaching Experience
Have you ever worked with a coach, counselor, mentor, or therapist before?
Is there anything you'd like your coach to know about you before your first session? This could be anything — something going on in your life, a communication style that works best for you, something you've been thinking about, or anything you want them to know.
Is there anything you'd prefer your coach NOT bring up or focus on during sessions? Your comfort matters. You're in charge of what we talk about.
SECTION 5: Logistics & Availability
What is the best way for your coach to reach you to schedule sessions?

Other
Generally, what times work best for you for a 30-minute coaching session?
SECTION 6: Agreements & Consent
Confidentiality Agreement. Please read and check the box below:
Ready to Go? How are you feeling about starting your first coaching session?
🦋 Thank You!
You just took your first step. Your coach will reach out soon to schedule your first session. In the meantime, if you have any questions, message us on Circle or email Ms. Joy at joy@butterflydreamz.org.

Remember: wellness coaching is your space. You set the agenda. You drive the conversation. We're just here to help you get where you want to go. 💙
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TMHA Wellness Coaching Intake Form

SECTION 1: About You

SECTION 2: How Are You Doing?

SECTION 3: Your Strengths & Goals

SECTION 4: Your Wellness Coaching Experience

SECTION 5: Logistics & Availability

SECTION 6: Agreements & Consent