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Wellness Coaching Package Intake Assessment
I am looking forward to our first appointment. Please take some time to fill in the information in this assessment the best that you can. Thank you.
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Name
*
Your answer
Email
*
Your answer
Birthdate
MM
/
DD
/
YYYY
Current age
1 point
Your answer
Telephone, including country code
Your answer
Where do you live? Please include City, State, and Country.
Your answer
What country are you from originally and/or what is your cultural background?
1 point
Your answer
What time zone do you live in?
Your answer
Single? Married? Divorced?
Single
Married
Divorced
In a relationship
Other:
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Do you have children? If yes, how many and what are their ages?
Your answer
Do you work? If yes, what is your job and how many hours each week?
Your answer
Do you live alone or with family/friends?
Your answer
What times and days of the week do you prefer appointments? Please specify timezone in the time.
Your answer
Does anyone else in your household have chronic illness?
Yes
No
Other:
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How did you find me?
1 point
Website
Google or Internet Search
Referral
Social Media
Other:
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