Coaching Session Application
Health & Wellness Coaching at Sarasota Memorial Health Care System
Today's Date
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Month
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Day
Year
Date
Name
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First Name
Last Name
Date of Birth
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Month
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Day
Year
Date
I am...
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A current SMHCS employee
A family member of a current SMHCS employee
A community member
Phone Number
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Email
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example@example.com
Race (self-identified)
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Please Select
American Indian / Alaskan
Asian
Native Hawaiian / Other Pacific Islander
Black / African American
White / Caucasian
Hispanic / Latino
More than one race
Unknown / Opt out
Gender (self-identified)
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Female
Male
Other/Opt out
Do you currently have active cancer?
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Yes
No
Do you currently have, or are in recovery for, an eating disorder?
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Yes
No
Health & Wellness Coaching Details
Please explain your goals for health & wellness coaching below:
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Which stage of change do you believe you are currently in?
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"I'm aware that a problem exists and I am seriously thinking about overcoming it, but have yet to take action."
"I intend to take action very soon. I need a plan and support to get started."
"I've already started to take action to address my problem. I need support and accountability to continue my progress."
Coaching Availability
What does your availability for coaching look like? Please provide preferred days & times.
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Coaches are available Mondays-Fridays
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