Health & Wellness Coaching Intake Form

Thank you for completing this intake form for health and wellness. The information you provide will be held in a strictly confidential manner, in compliance with HIPAA and professional ethics. Your willingness to share pertinent information is useful in planning Personalized Integrative Health Coaching. Please know that you may choose to complete as much or as little of the intake form as you’d like. You are always at choice in the coaching process.

Name

First Name

Last Name

Phone

(###)

###

####

Preferred Contact Method

Date of Birth

Gender

Pronouns

Self-rating of current health status:

Health Conditions (optional to disclose):

Is there anything that is important for your coach to know about your physical health?

What has motivated you to participate in health coaching at this time?

Please rate your stress level on a scale of 0-10 (0= no stress; 10 = most stress possible):

What are the biggest stressors you experience now?

What do you currently do to cope with stress?

What do you consider to be your three greatest strengths?

What do you consider to be your top three core values?

How does your current health impact your aspirations and goals in life?

What is your vision of an ideal future?

What else would you like your health coach to know about you?