Health Coaching Intake Form
This helps me be a little more prepared for your short phone consultation, that's all!
Name *
First and last name
Your answer
What is your date of birth? *
MM
/
DD
/
YYYY
Are you male or female? Please note that I specialize in women's health, and do not consider myself a good fit for male clients. *
Email *
Your answer
Phone number *
Your answer
What is your preferred method of communication?
Have you worked with a health coach before? *
What is your experience with health coaching? *
Required
Have you been given health goals by a doctor or other medical professional? Select all that apply. *
Required
Do you have any health issues? Please list any diagnoses given to you by a health care practitioner. *
Your answer
Do you suspect any other health issues yourself? *
Your answer
Do you have any complaints about your physical health? Select all that apply. *
Required
Think about food. Which of these statements do you agree with? Select all that apply. *
Required
Do you have any complaints about your general wellbeing? Select all that apply. *
Required
Which of all these complaints (physical, diet, general) is most important in YOUR opinion to fix?
Your answer
What times are you available? (please note that my current availability is Monday through Friday, 6am - 5pm). *
Will you adhere to a cancellation policy that requires 12 hours notice before cancelling a coaching session (or you are charged the full amount of the session)? *
How did you hear about me? *
Is there anything else you'd like to tell me in advance?
Your answer
Thank you!
After reviewing your information, you can expect to hear from me via your desired method of communication to set up a quick phone call. The point of the call is essentially for you to "interview me" and determine if I would be a good fit in your healthcare team. Remember, you're the boss, so be as picky as you can about who you hire!
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