Health Evaluation

Be Nourished 360 Health Coaching Intake Form

Welcome to Be Nourished 360. This form will help me gain a deeper understanding of your health history, daily habits, wellness goals, and current challenges so we can create realistic, sustainable steps forward together. Please take your time and answer openly. I’m honored to support you on your journey toward feeling healthier, stronger, and more like yourself again.— Nikki Zurcher | Be Nourished 360
Full Name

First NameLast Name
Address

Street Address

Address 2

CityState / Province

Postal / Zip Code
Phone Number
Format: (000) 000-0000.
E-mail
example@example.com
How did you hear about Be Nourished 360?
What is your main motivation for wanting to make changes in your health/life?
Can you tell me about a time in your life when you were healthier or felt more like yourself? What has changed between then and now?
What have you tried in the past? What worked? What did not work? What stopped you from reaching your goals?
When you make these changes and reach your goals, how will this benefit your life? What will you be able to do? What will you be able to stop doing?
On a scale of 1-10, how excited are you about taking steps to improve your life? 10 being the MOST excited, 1 being the LEAST
Medical History
Do you have any of the following:

Other
If yes to any of the above, please explain:
Medications/Supplement List, including dosage and frequency:
Sleep and Energy
How many hours of sleep do you get in a typical night?
How would you describe the quality of your sleep?
On a scale of 1-10, what is your energy level throughout the day? 10 being the most energetic, 1 being the least
Have you ever participated in a sleep study? If so, results?
Movement
How many hours a day do you sit?
How many days a week do you exercise? (0 - 7 days)
Describe your exercise/activity level: (Frequency, Intensity, Duration):
What is your biggest hinderance to being more active/exercising?
Mind
On a scale of 1-10, how fulfilled are you?
On a scale of 1-10, how much do you worry?
What area of your life tends to be the biggest stress for you?
What do you do for work?
On a scale of 1-10, how much do you enjoy what you do?
Do you feel confident in your ability to adapt to change?
Do you consider yourself to be more extroverted or introverted?
Food and Hydration
How many meals and snacks do you eat per day?
When do you eat your first meal of the day?
When do you eat your last meal of the day?
How many ounces of water do you drink per day?
Do you drink other beverages? Coffee, soda, alcohol, tea, etc.
If so, how often and how much?
Which diets have you tried in the past? (Keto, Paleo, Gluten Free, Vegan, Intermittent Fasting, etc.)? How did it go for you?
Biggest struggles with food?
WEIGHT MANAGEMENT
Age:
Height:
How much do you currently weigh?
What would you consider to be a healthy weight for you?
Have you tried to lose weight in the past?
What has been difficult for you about losing and maintaining weight?
Social/Emotional Support
On a scale of 1-10, how healthy would you rate your relationships? (This includes: healthy friendships, supportive family, connections in your church or community)
Is there anyone in your life who would like to get healthy with you?
On a scale of 1-10, do you feel supported, safe, and loved in your home environment?
Is there anything else you think I should know about your health or your life?
Coaching Agreement & Consent

Please read the following agreement carefully before signing below.
BE NOURISHED 360
HEALTH & WELLNESS COACHING AGREEMENT, INFORMED CONSENT & LIABILITY WAIVER

Coach: Nicole Zurcher
Business: Be Nourished 360
Website: benourished360.net
Email: nikkiz@benourished360.net
OVERVIEW

Welcome to Be Nourished 360. This agreement outlines the expectations, policies, and terms of participation for health and wellness coaching and consulting services provided by Nicole Zurcher, Health & Wellness Coach.

By participating in coaching and consulting services, the Client acknowledges and agrees to the following:

COACHING AND CONSULTING SERVICES

Be Nourished 360 provides health and wellness coaching and consulting intended to support clients in improving overall wellness through education, accountability, encouragement, goal support, and sustainable lifestyle practices.

Coaching and consulting may include discussions related to:

nutrition and wellness habits
mindset and behavior change
stress management
movement and lifestyle support
emotional wellness
accountability and goal implementation

Membership Includes:

First Month: Four (4) private 1:1 coaching sessions
Ongoing Months: Two (2) private coaching sessions per month
Sessions up to 60 minutes
Support between sessions via text, email, Voxer, or Facebook Messenger

COACHING RELATIONSHIP & INFORMED CONSENT

The Client understands that Nicole Zurcher is acting solely as a Health & Wellness Coach and Consultant and is not functioning as a physician, registered dietitian, licensed therapist, psychologist, or medical provider.

The Client understands that coaching services:

do not diagnose disease
do not prescribe medications
do not treat mental health disorders
do not replace medical advice, medical treatment, or mental health care

The Client agrees to consult with a qualified healthcare provider regarding any medical concerns, symptoms, medications, diagnoses, or treatment decisions.

The Client voluntarily chooses to participate in coaching services and accepts full responsibility for their health choices and lifestyle decisions.

CLIENT RESPONSIBILITY

The Client understands that all decisions, actions, and results are the responsibility of the Client.

Coaching is a collaborative process intended to support personal growth and wellness goals; however, results are not guaranteed.

The Client understands that individual outcomes vary and that no promises or guarantees are made regarding:

weight loss
symptom improvement
disease prevention
emotional outcomes
physical results
PAYMENT & MEMBERSHIP TERMS

The Be Nourished 360 coaching membership is billed at $98 per month and renews automatically each month unless canceled by the Client.

Membership is month-to-month and may be canceled at any time prior to the next billing cycle.

Payments are non-refundable.

CANCELLATION & RESCHEDULING POLICY

Clients are asked to provide at least 24 hours’ notice for canceled or rescheduled appointments.

Missed sessions or cancellations with less than 24 hours’ notice may result in forfeiture of that session.

COMMUNICATION BETWEEN SESSIONS

Reasonable support between sessions is available during normal business hours through:

text messaging
email
Voxer
Facebook Messenger

While Nicole Zurcher strives to respond in a timely manner, immediate responses are not guaranteed.

EMERGENCY DISCLAIMER

Coaching services are not intended for emergencies or urgent medical or mental health situations.

If the Client is experiencing a medical emergency or mental health crisis, the Client agrees to contact 911, their physician, licensed mental health provider, or emergency services immediately.

CONFIDENTIALITY

Client information shared during coaching sessions will be kept confidential to the best of the Coach’s ability unless disclosure is required by law or necessary to prevent harm.
LIABILITY WAIVER

By participating in coaching services, the Client voluntarily assumes all risks associated with implementing lifestyle, nutrition, movement, wellness, or habit changes discussed during coaching sessions.

The Client releases and holds harmless Nicole Zurcher and Be Nourished 360 from liability related to injuries, damages, losses, or adverse outcomes that may arise from participation in coaching and consulting services.

AGREEMENT
By signing below, the Client confirms that they have read, understood, and voluntarily agreed to the terms outlined in this document.
I have read, understood, and agree to the Coaching and Consulting Agreement, Informed Consent, and Liability Waiver above.
Client Signature
Date of Signature

MonthDayYear
Date
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Be Nourished 360 Health Coaching Intake Form

Medical History

Sleep and Energy

Movement

Mind

Food and Hydration

WEIGHT MANAGEMENT

Social/Emotional Support

Coaching Agreement & Consent