Coaching Client Intake Form
Name
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First Name
Last Name
Email
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example@example.com
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
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Please enter a valid phone number.
Your Date of Birth
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Month
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Day
Year
Date
Your Height & Weight
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How did you hear about us?
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Please Select
www.jesscrutchfield.com
web search
facebook
instagram
friend referral
google
yelp
other
Have you ever worked with a health coach or other coach before? Please describe:
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What are your top three concerns you’d like to work on with me?
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What do you hope to achieve out of your experience with health coaching?
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What coaching style brings out the best in you? Said another way, what's the best way I can coach you most effectively? (feel free to share what you can, or write "I'm not sure.")
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What tips would you give me about how you operate/your learning style/your personality?
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Are you currently seeing a medical doctor? Using Health Insurance? Conventional or Functional? Other?
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Are you currently in counseling of any kind? If yes, please describe.
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On a scale of 1-5, with 5 being extremely satisfied, how would you rate your level of satisfaction in each of the wellness areas below?
Describe in the space why you gave the answer you have.
1-5 Nutrition (is it on point for you, still needing tweaking, an area you need major help?)
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1-5 Exercise/Movement (including what types of exercise/movement you like, how often, and why you do them)
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1-5 Sleep (and include how many hours you do sleep, whether it's hard to fall or stay asleep, whether you feel rested, if you have any routines before/after sleep, or anything else I should know about your sleep)
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1-5 Stress (including how stressed you're feeling currently and what your biggest stressors are)
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1-5 Relationships (with other people and especially your relationship to yourself)
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1-5 Awareness of environmental toxins & how they affect your health. Do you make efforts to reduce your exposure? (i.e. water filters, reducing use of plastic, making conscious choices with personal care products, etc..).
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Has a doctor/health care practitioner (or you) ever been concerned about any of the following? (check any that apply/make note in the next question if applicable)
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Weight
Blood Sugar Levels
Family History
Heart Conditions
Smoking/Tobacco Use
Hormone Levels
Vitamin Deficiencies
Autoimmune Diseases
Food Allergy
None of These
Other
Please explain what you've checked above, detailing date of occurrence and any pertinent information. If there are other persistent symptoms you have such as acne, headaches, toxicity, gut bacteria overgrowth, irregular periods, constipation/diarrhea, etc, note them here:
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Have you had any major injuries, surgeries, or health conditions that will affect your long-term health and wellness? If yes, please explain:
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Do you consume/use any of the following? Check all that apply
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Cigarettes
Nicotine vape pen/other
Cannabis
Frequent use of Medicinal plants
Medicine journeys/conscious use and purpose of medicinal plants
Alcohol
Tap water or plastic bottled water
Synthetic personal care or cleaning products
Canned foods
None of These
Other
Do you take any medications? If yes, please list along with reasons why (hormonal birth control included):
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Do you take any supplements (herbs, vitamins, etc.)? If yes, please list and include frequency:
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Please describe your current intake of nutrients in a typical day/week/month. Consider the macronutrients protein, fat, and carbohydrate intake you have now, as well as micronutrients, to the best of your ability. Describe generally what your diet consists of, and what you do not eat (ie gluten-free, vegan, paleo, etc)
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How much water are you drinking daily in ounces? Estimate as best you can. Are you satisfied with this amount? What are you drinking when not drinking water?
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Please describe how frequently you have bowel movements and what their consistency is like (ie soft vs the perfect log). What volume do you eliminate daily?
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Tell me about your living situation, your peer group, and other support systems you have:
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What do you do to relieve stress? How often? What do you do to have fun? How often?
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What obstacles might be holding you back from achieving your health goals and living your most vital and aware life possible?
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Is there anything else you’d like to tell me that you feel would be valuable for me to know and inform our coaching together?
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I understand that I will be working with a health coach and will not be treated for any medical or psychiatric conditions, given laboratory evaluations or assessments, nor prescribed meal plans/workouts. Jess is a Health Coach working as a partner with me in achieving my health and wellness goals.
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I acknowledge
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