Intake Form
Please fill in this form with as much detail as you are comfortable sharing. This is our opportunity to begin a strong and trusting coaching relationship together.
Email address *
Phone *
Your answer
Full Name *
Your answer
Age *
Your answer
Goals and Outcomes
Take some time to identify three life goals or ideal outcomes you would like to achieve. To give yourself the greatest chance of success, your goals should be challenging, positively stated, reasonable, and as specific as possible. For each goal/outcome, answer the following:

Why is this goal important to you?
How will you feel once you achieve the desired outcome?
What habits are getting in the way of achieving this outcome?

Here's an example:
Goal/Outcome: Achieve 15% body fat.
This is important to me because I am self-conscious about my weight, worried about my health, and tired all the time.
Achieving this goal, I will improve my self-confidence and energy while reducing stress about my health.
I currently struggle with eating to much sugar, emotional eating, overeating, and a lack of exercise.

Goal/Outcome #1 *
Your answer
Goal/Outcome #2 *
Your answer
Goal/Outcome #3 *
Your answer
What are you hoping to gain from health coaching? *
Your answer
How can I bring out your best? *
Your answer
Current Health Challenges
What are you current health and fitness challenges? *
Your answer
Are you engaged in any treatments (conventional or alternative) related to these health challenges or issues? If yes, please explain. *
Your answer
Are there any patterns that seem to repeatedly appear in regards to your health? Explain. *
Your answer
Support System and Significant Events
I’d like to know about your current support system. Please share more about the practitioners, medical doctors and specialists, nutritionists, trainers, therapists, naturopaths, family, and friends who support your health and well-being. *
Your answer
Learning about your past helps me to gain a better understanding of your health and fitness journey. Please list a few significant events that you feel are relevant. Do you anticipate any significant life events in the near future? *
Your answer
Your Relationship with Yourself
How is your self-talk? Does it tend to be positive or negative? *
Your answer
How do you feel about your ability to transform your lifestyle? *
Your answer
How would you rate your self-discipline? How often do you fulfill the commitments that you make to yourself? *
Your answer
Lifestyle
Which aspects of your home life contribute your health and fitness? *
Your answer
Which aspects are challenges? *
Your answer
Which aspects of your work environment contribute your health and fitness? *
Your answer
Which aspect are challenges? *
Your answer
How do you cope with stress on a day-to-day basis? Do you currently employ any stress-management techniques? *
Your answer
Tell me about your interests, hobbies, and passions. *
Your answer
Physical Activity
On average, how many times per week do you engage in physical activity? *
Describe your physical activity. Please include type, duration, and frequency. *
Your answer
Rate the importance of physical activity in your life. *
Unimportant
It's my top priority.
Rate your willingness to make changes or improvements to your physical activity routine. *
Not willing to change.
When do we start?
Please explain any physical limitations regarding exercise or movement. *
Your answer
Diet and Nutrition
Please, remember that your accuracy and honesty is vital to our success!
Please list the typical foods and beverages you consume in the average. Include quantities if possible. *
Your answer
Do you smoke? *
Do you use any recreational drugs? If so, please include frequency and amounts. *
Your answer
Please list all supplements (including herbs) that you are currently using. Were they prescribed by a medical professional? Please include dosage, reason for use, and how long you've been taking them. *
Your answer
Sleep and Stress
On average, how many hours do you sleep each night? *
What is your usual sleep schedule? *
Your answer
Rate your sleep quality. Do you wake up feeling refreshed? *
Rate your stress level. *
Anything else you'd like to add?
Please include any other questions, comments, or information that you have.
Your answer
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