• Essential Wellness Coach

    Essential Wellness Coach

    Assessment Form

  • Personal Information

  • Date
     - -
  • Format: (000) 000-0000.
  • Marital Status

  • General Health

  • Surgeries
  • Have you experienced any of the below?
  • How often do you wake at night?
  • How frequently do you exercise?

  • Nutrition and Eating Habits

  • What is your water intake per day?
  • What is your caffeine intake per day?
  • Do you smoke?
  • Do you take or use any of the following:

  • Assessment Form

    Please tick relevant boxes, past or present ailments.
  • Check all that apply (past or present):
  • Do you currently have any of the following skin issues?
  • Do you currently have any of the following digestion issues?
  • Do you currently have any of the following circulation problems?
  • Do you currently have any of the following nervous system issues?
  • Do you currently have any of the following respiratory issues?
  • Do you currently have any of the following muscle problems?
  • Do you currently have any of the following urinary issues?
  • Do you currently have any of the following endocrine issues?

  • For Women

  • Have you ever experienced the following:
  • Have you ever experienced the following:

  • For Men

  • Have you ever experienced the following:
  • Have you ever been diagnosed with:
  • Emotional Issues:
  • Mental Issues:
  • Stress:
  • How would you rate your stress level?Type a question

  • Additional Information

  • Statement

    Scope of Services:I, the undersigned (Client Sign), understand that I am seeking coaching services from Essential Wellness Coach for the purpose of personal development, self-improvement and self-care. These sessions may include discussions related to complementary and alternative medicine and therapies and will be used as case studies. We do not offer once off services, we offer a multiple sessions packaged to serve and transform your well-being.

  • Indemnity Form

    Responsibilities and Acknowledgments: Voluntary Participation: I acknowledge that I am voluntarily participating in coaching sessions and any complementary or alternative therapies or practices discussed or recommended by the coach. Non-Medical Advice: I understand that the coaching services provided by Essential Wellness Coach Loreal Nel are not a substitute for medical or psychological diagnosis, treatment, or advice. The coach does not provide medical, psychological, or therapeutic services. Personal Responsibility: I take full responsibility for my physical and emotional well-being during and after coaching sessions. I understand that I should consult with a qualified healthcare professional regarding any physical or mental health concerns. Confidentiality: I understand and agree that the content of our coaching sessions will be kept confidential, with the following exceptions: (a) if I pose a threat to myself or others, (b) if I disclose information about child or elder abuse, or (c) as required by law. Informed Decision: I have had the opportunity to ask questions and seek clarification regarding any aspect of the coaching process, including the use of complementary or alternative therapies. Indemnity: I release and hold harmless Essential Wellness Coach Loreal Nel, their associates, and any third parties referred to for complementary or alternative therapies, from any liability, claims, demands, actions, causes of action, costs, and expenses arising out of or in any way connected to my coaching sessions. Consent and Agreement: I have read and understand the terms and conditions outlined in this Coaching Indemnity and Consent Form. By signing below, I agree to abide by these terms and release Loreal Nel from any liability associated with my coaching sessions. I (client) take responsibility for my own well-being.
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