COPIA Health Client Intake Form
Greetings,

Welcome to COPIA Health! I am excited to be your integrative health & wellness coach. Before we meet I’d like some information about you, your goals, and your perspectives. It is important for me to understand how you view the world, as each person comes from a unique place in their thinking and the way they interact with those around them. Please complete the following activities before our next session. Take your time. These activities were designed stimulate reflection in a way that will make our work together more productive.

Feel free to email megan@copiahealth.com or call 415.326.3184 if you have any questions about this material. I look forward to partnering with you as you discover your unique path to wellness!

Sincerely,
Megan

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Your answer
Email *
Your answer
Mailing Address *
Your answer
Preferred phone number *
Your answer
Career / Occupation *
Your answer
Date of Birth *
Your answer
Coaching Questions
1. What motivated you to seek a coach? *
Your answer
2. Have you worked with a health/wellness coach or life coach before? If so, please share a little about your experiences. *
Your answer
3. What are your expectations of this coaching experience? *
Your answer
4. What is the “best” way for me to coach you most effectively, what tips would you give to me about what would work best? *
Your answer
5. Do you have any apprehension or pre-conceived ideas about coaching? *
Your answer
6. What are your top five health and wellness goals?
Your answer
Health and Wellness Information
Note: As your coach, my job is to be an ally and a resource. My job is not to diagnose you or provide treatment. I can help you discover steps you may take towards greater health and higher levels of wellness. If you have needs outside of the scope of wellness coaching, I can refer you to medical, psychological, or other health-related services. I can be a source of support, information, and accountability, helping you to follow through with any treatment plans that you devise with other health professionals.
1. What are your current health and wellness practices? *
Consider: nutrition/eating, time in nature, exercise/movement, stress reduction activities, spiritual practice, relationships/community, sleep, exercise, stress management, spiritual practice, play and recreation, etc.
Your answer
2. What health issues—major or minor—do you currently experience? *
Your answer
3. Who do you consider your healthcare team? *
Please describe the practitioners (e.g. medical doctors and specialists, nutritionists, therapists, naturopaths, friends and family) who support your health and wellbeing.
Your answer
3. Are you engaged in any treatments (conventional or alternative) related to the above health issues? If so, please describe them. *
Your answer
Reflection Questions
The following questions were designed to stimulate reflection and provide me with basic information. Answering them clearly and thoughtfully will serve both you and I. Take your time, and fill out the sections that feel most relevant—the more, the better. This is the start to a meaningful and productive coaching relationship. As with all information you share with me as your coach, your answers will be treated with complete professional confidentiality.
Mindset Questions
These are questions about your beliefs regarding your health and wellbeing.
What are your beliefs about health and wellbeing? *
Where did these beliefs come from?
Your answer
What are your beliefs about your personal value or worth? *
Your answer
What are your beliefs about your ability to heal yourself? *
Your answer
Relationships, Love, and Passion Questions
1. How satisfied do you feel with your romantic life? *
Your answer
2. What are the repetitive relationship patterns you have noticed appear again and again in your life? *
Your answer
3. In relationships, how willing are you to compromise? forgive? communicate needs and boundaries? receive love? *
Your answer
4. How willing are you to be vulnerable with others?
Your answer
5. Please describe your most significant relationships in your life (romantic or not, positive or not). *
Your answer
Environment Questions
1. What aspects of your home life and environment support your health and well-being? What aspects detract from your health and well-being? *
Your answer
2. What do you like most about the community where you live? What do you like least?
Your answer
3. What environmental toxins might you be exposed to regularly?
Your answer
4. How much time do you spend in nature?
Your answer
5. Please describe your relationship with technology.
Your answer
6. Do you have unnecessary clutter in your life or environment? *
How might you minimize this?
Your answer
Self-Inquiry
These are questions designed to have you consider your relationship to your intuition and higher self.
Do you have a meditation or other self-inquiry practice? *
Your answer
What does your intuition tell you about what you need to bring balance to your health and wellbeing? *
Your answer
Are there things in your life right now that you know are true at a deeper level, but you are unwilling to acknowledge of accept right now?
Your answer
Work/Career Questions
1. What aspects of your work life and environment support your health and well-being? What aspects detract from your health and well-being?
Your answer
2. What do you want from your work/career? What are your key work/career goals?
Your answer
Lifestyle Questions
2. What do you do to reduce stress in your life, or to counteract the effect of stress in your life?
Your answer
3. Do you think you would benefit from learning new approaches?
Your answer
4. What aspects of your life bring the greatest challenges for you?
Your answer
5. How would you rate your sleep?
6. On average, how many hours of sleep do you get per night?
Your answer
7. Please check any sleep concerns you have:
Personal Questions
1. What do you do in your life that brings you happiness and joy? How often do you do this?
Your answer
2. What unique talents, gifts or knowledge do you have?
Your answer
3. What do you do when you are really stressed and feel up against the wall?
Your answer
4. Do you have a religious practice, spiritual base or belief system? If so, how do you draw upon your spiritual beliefs for support and to help you with facing challenges in your life?
Your answer
5. What is missing in your life, the presence of which would make your life more fulfilling?
Your answer
6. Do you have a secret passion? Something you may or may not have allowed yourself to do so far, but which you would really love to do.
Your answer
7. What gives you a sense of purpose in life? What activities have meaning for you?
Your answer
8. What accomplishments or events must occur during your lifetime to consider your life satisfying and well lived?
Your answer
9. What else would you like your coach to know about you?
Your answer
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