Level One Health Coaching Program: Align Integrative Wellness
Level One Membership Includes:
Two- 30 Minute One on One Health Coaching Sessions per month
Online Wellness Content and Topics: Meditation, Mindfulness Practice, Goal Setting, Nutrition Support, Sleep and Stress Management
Resource Library:
Yoga and Meditation
Strength and HIIT Workout
Monthly Coffee Hour via Zoom
Monthly Book Club via Zoom
Motivation, Accountability and Align Community Member Support


COST: $100

How to Register:
Complete the Health Intake Form Below

Payment: We will send you an invoice after we receive your email!
Payment Options- PayPal, Venmo, ACH Debit, Check
After, we will send you a link to set up your Welcome Call!
Sign in to Google to save your progress. Learn more
Name: First and Last
Email *
Age
Date of Birth
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Address
Phone number
Relationship Status
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Occupation/ Hours of Work Per Week
Health Information: Please describe your overall health:
Please list your main health concerns:
Current Height and Weight
What was your weight six months ago?
Would you like your weight to be different? If so, WHY?
Food or Medication Allergies or Sensitivities
Do you take any supplements or medications? Please list name, dosage and indication:
Do you have a history of any serious illnesses/hospitalizations/surgeries?
Any current/chronic illnesses/injuries?
Any pain/stiffness/swelling?
Digestive Issues: Constipation/diarrhea/burping/gas? If so, does anything specific cause it?
Clear selection
Do you smoke cigarettes?
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Any recreational drugs?
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Any other healers, helpers, or therapies with which you are currently involved?  
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Is your daily schedule regular or does it vary from day-to-day?
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How is your Sleep?    How many hours per night?
Do you feel rested upon wakening?
Very Tired
Well Rested
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How is your overall energy level?
Low Energy
High Energy
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What role does exercise play in your life?
At what point in life have you felt your best?
Food Info: Do you follow a certain diet or nutrition plan? If yes, what is it?
How many meals a day do you eat?
How many snacks per day?
Please record what you eat in a typical day:  Breakfast, Lunch, Dinner, Snacks, Beverages
Do you cook? If not, who does a majority of the cooking?
Where do you get your food from?
How many meals per week are take-out or dine in restaurants?
Do you have any food cravings or aversions?
How much alcohol do you consume?
How much caffeine do you consume?
Are you satisfied with your diet? Is there anything you would like to change?
Mental/emotional health: Do you have a history of Anxiety?
Do you have a history of depression?
History of any other mental health concerns?
What is your current level of stress?
No stress
Stressed to the Max
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Do you feel you can easily handle the stress in your life?
Who/what do you utilize for emotional/mental support?
What gives you the greatest joy in life?
GOALS: What do you hope to achieve by doing this program?
Did something happen to trigger a change in your health status?
What makes you feel better?
What makes you feel worse?
What is the most important thing you could do to improve your health?
What do you see as the main obstacles to achieving your health goals?
Is there anything else you would like to share about yourself in order for us to best support you?
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