Health & Wellness Coaching Intake

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Please fill out this form to help us understand your health and wellness goals and background.

Email *

Full Name

Email Address

Phone Number

Age

Occupation

Referred By

What is your #1 wellness goal right now?

Which best describes your current focus?

Weight loss & body composition

Energy & fitness

Stress reduction & lifestyle balance

Nutrition & healthy routines

Clear selection

How soon are you ready to begin?

Immediately

Within 30 days

In the next 3–6 months

Clear selection

Do you currently take weight loss injections (GLP-1, etc.) prescribed by a provider?

Yes

Clear selection

Do you have any physical limitations we should know about?

Do you currently exercise regularly?

Yes, 3+ times per week

Yes, 1–2 times per week

No, but ready to start

Clear selection

On a scale of 1–10, how would you rate your overall stress level?

Low

Very high

Clear selection

Non-Disclosure Agreement (NDA) *

Non-Disclosure Agreement (NDA)

Purpose
This agreement protects the confidentiality of all strategies, systems, and materials shared during coaching. It also protects the privacy of the client’s personal and health-related information.

Confidentiality

Client agrees not to share, copy, or distribute any proprietary coaching materials, frameworks, or strategies without written consent.
Coach agrees to keep all personal and health-related information confidential, except when required by law or safety concerns.

Term
This agreement remains in effect for two (2) years after coaching services end.

I have read, understood, and agree to the terms of the Non-Disclosure Agreement.

Required

Waiver & Release of Liability *

Non-Disclosure Agreement (NDA)

Confidentiality

Client agrees not to share, copy, or distribute any proprietary coaching materials, frameworks, or strategies without written consent.
Coach agrees to keep all personal and health-related information confidential, except when required by law or safety concerns.

Term
This agreement remains in effect for two (2) years after coaching services end.

I have read, understood, and agree to the Waiver & Release of Liability.

Required

Coaching Contract / Agreement *

Waiver & Release of Liability

Purpose
Health & Wellness Coaching is designed to support lifestyle, accountability, nutrition, and fitness goals. Coaching is educational and supportive — it does not replace medical treatment.

Assumption of Risk

Client understands lifestyle and fitness changes carry inherent risks.
Client agrees to consult with their prescribing provider and/or physician before beginning new nutrition or movement routines.

Release of Liability

Client releases and holds harmless Coach LT from any claims or damages resulting from participation in coaching services.
Client accepts full responsibility for their own health choices and outcomes.

I have read, understood, and agree to the Coaching Contract & Terms of Service.

Required

Please type your full legal name as your signature.

Date

YYYY

A copy of your responses will be emailed to the address you provided.

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