OptiMOM Coaching Initial Intake Form
These initial questions will give us a frame to build your work on. You'll be asked to list 3 preferred days and times that work best to connect. Remember, your 1st session will last approximately 90 minutes. Subsequent sessions are approximately 50 minutes.
Full Name: *
Date of Birth: *
Email address: *
Mailing address: *
Phone number you'll use for our calls: *
What are your preferred dates and times for us to connect? Please provide at least 3. *
If you work outside the home, what is your occupation and do you enjoy your work?
Are you a parent? If yes, please list your children (s) names and ages.
If you're a parent, do you currently like being a parent?
(no judgement, I promise...and your answers are confidential)
How did you learn about OptiMOM Coaching? *
What is the rate of satisfaction with your diet/nutrition? *
Dissatisfied
Completely Satisfied
What is the rate of satisfaction with your physical activity? *
Dissatisfied
Completely Satisfied
What is the rate of satisfaction with your sleep/rest? *
Dissatisfied
Completely Satisfied
What is the rate of satisfaction with your stress relief/relaxation? *
Dissatisfied
Completely Satisfied
What is the rate of satisfaction with your most important relationships? *
Dissatisfied
Completely Satisfied
What is the rate of satisfaction with your emotional health? *
Dissatisfied
Completely Satisfied
What is the rate of satisfaction with your spiritual health? *
Dissatisfied
Completely Satisfied
What is the rate of satisfaction with your medical state of health/screenings? *
Dissatisfied
Completely Satisfied
What is at least one thing you'd like to do more of in your life right now? *
You can list more.
What is at least one thing you'd like to do less of in your life right now? *
You can list more.
Are your currant lifestyle choices negatively effecting anyone in your life right now? *
If yes, who?
When you set a goal, how likely are you to meet it?
(skip if you rarely or never set goals)
Never reach my goals
Always reach my goals
Clear selection
The following questions are about how you have been feeling during the past four weeks. For each question, please select the one answer that comes the closest to the way you have been feeling, on a scale of 1 to 5:
1. None of the time
2. A little of the time
3. Some of the time
4. A good bit of the time
5. All of the time
How much of the time during the past four weeks have you felt calm and peaceful? *
None of the Time
All of the time
How much of the time during the past four weeks did you have a lot of energy? *
None of the Time
All of the time
How much of the time during the past four weeks have you been a happy person? *
None of the Time
All of the time
How much of the time during the past four weeks did you take the time to relax and have fun daily? *
None of the Time
All of the time
How much of the time during the past four weeks have you felt anxious, depressed, downhearted or blue? *
None of the Time
All of the time
How much of the time during the past four weeks have you felt worthless, inadequate, or unimportant? *
If you answer 3 or higher, I will ask you to complete a depression evaluation.
None of the Time
All of the time
Listed below are some typical results experienced by coaching clients. Which 3 are most important to you? *
Required
Do you already have specific goals you'd like to address in our work together? *
If yes, please describe them.
Please use this space to ask any questions or offer any additional information that you think would be helpful before we begin.
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