Health Coaching Intake Form
This helps me be a little more prepared for your short phone consultation, that's all!
First and last name
What is your date of birth?
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.
What is your preferred method of communication?
Have you worked with a health coach before?
What is your experience with health coaching?
no idea what it is
health coaching is something I have researched on my own
my doctor recommended it, that's the only reason I am inquiring
I am hesitant to start
I am excited to start
Have you been given health goals by a doctor or other medical professional? Select all that apply.
eat a healthier diet
increase daily activity
get more sleep
alter cholesterol values
manage blood sugar
Do you have any health issues? Please list any diagnoses given to you by a health care practitioner.
Do you suspect any other health issues yourself?
Do you have any complaints about your physical health? Select all that apply.
low muscle mass
Think about food. Which of these statements do you agree with? Select all that apply.
I eat too much processed food
I have no time to cook at home
I rely on fast food
cooking healthy meals is hard
it's hard to eat fruit and vegetables
my family doesn't want to eat healthy with me
I feel like I can never be sure what information is "right"
healthy food is too expensive
I exerience "tummy issues" frequently
Do you have any complaints about your general wellbeing? Select all that apply.
too much/too little energy
"mental chatter", can't relax
hair loss/excess hair
lack of time
Which of all these complaints (physical, diet, general) is most important in YOUR opinion to fix?
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?
Word of mouth
Is there anything else you'd like to tell me in advance?
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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This form was created inside of Lift your LIFE with Laura.