Well & Simple Client Screening Questionnaire
Please fill out the following information so we may determine how Well & Simple may be able to serve you and whether we are the best fit for your needs. We will be in touch with you within 48 hours to schedule a consultation if we believe our services can meet your needs.
Email address *
Prospective Client Information
Please provide the following identifying and contact information so we may reach back out to you promptly.
Name *
Your answer
Phone *
Your answer
Occupation *
Your answer
Date of Birth *
MM
/
DD
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YYYY
Sex *
Preferred Pronoun *
Your answer
Why You Have Contacted Well & Simple
The following information will help us ascertain your needs and whether they fall within Well & Simple's scope of practice
Why are you seeking assistance from a health coach? What are your goals? *
Your answer
What other approaches have you take in the past to address these issues? (diet program, nutritionist, other health coach, etc) *
Your answer
How are the issues you listed above holding you back from your life, career, or aspirations? What would addressing those issues and reaching your goals do for your life? *
Your answer
Why do you feel that right now is the time to get started on this? *
Your answer
Do you think your friends and family will be supportive of you making changes to support your health? *
Your answer
What obstacles do you think have hindered you from addressing the above health goals in the past? *
Your answer
If Well & Simple chooses to work with me, I understand that this is an investment (of not only money, but time and energy as well) in my long-term health . *
Are you able to be available for health coaching appointments (whether in person, over the phone, or over video) between the hours of 8 am and 6 pm Monday-Friday? *
Well & Simple agrees to keep all client responses to this questionnaire confidential. By completing this questionnaire, you, the applicant, understand that this does not serve as contract, coaching agreement, or other guarantee that Well & Simple will be able to work with you as a client. If Well & Simple is able to take you on as a client, we will be in touch within 48 hours.
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