Client Intake and Screening Form
Welcome to Your Wellness Coaching Journey!
We know this form is in-depth, but rest assured that every question is designed to provide us with a full understanding of your unique needs, goals, and challenges. By taking the time to answer thoroughly, you're setting the stage for a successful coaching experience that is truly personalized to help you achieve lasting results. Your answers will guide us in tailoring a plan that supports your individual wellness journey, making every step of the process more effective and impactful. Thank you for your commitment!
DIETARY HABITS AND CONDITIONS
How often do you eat out / order delivery?*
How often do you eat refined / processed foods?*
Do you prepare your own food?*
Is eating organic products important to you?*
How frequently do you use tobacco?*
How frequently do you consume alcohol?*
How frequently do you consume caffeine?*
How frequently do you use drugs?*
Are you open to lab testing to determine your nutritional biochemistry for optimal feedback?*
Movement, Stress, and Rest
How many times a week do you do vigorous activity?*
How many times a week do you do moderate activity?*
How many times a week do you do light activity?*
How stressful would you rate your job?*
How stressful would you rate your life?*
How many hours of sleep do you typically average per night?*
Have you experienced any eating disorders during adolescence or adulthood*
How would you rate your stability / balance?*
How would you rate your stamina?*
How would you rate your strength?*
How would you rate your cognitive abilities?*
How would you rate your emotional regulation?*
How would you rate your connection to loved ones?*
How would you rate your connection to yourself?*
How would you rate your romantic connections?*
How would you rate your strive for personal development?*
How would you rate your work-life balance?*
