Client Intake & Assessment — Health & Life Coaching

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Health & Life Coaching

Client Intake & Assessment

Client intake & assessment form

Welcome! Please complete this form before your first session. Your answers are strictly confidential and help your coach understand you better and tailor your experience.

🔒 Confidential — your information is protected

Section 1 — Personal information

Full name

Date of birth

Email address

Mobile phone

Gender identity optional

Occupation / role optional

Emergency contact name

Emergency contact phone

Section 2 — Your goals & aspirations

What inspired you to seek coaching at this time?

What are your top 1–3 goals for our work together?

How would your life look different when you achieve these goals?

What has held you back from reaching these goals in the past?

What type of coaching support resonates most with you? select all that apply

Section 3 — Health & medical history

This information is strictly confidential and used only to support your coaching.

Health conditions or diagnoses you've been informed of write 'None' if not applicable

Prescription medications name & purpose

Supplements or over-the-counter optional

Current energy level

1 — Low / depleted10 — High / thriving

Current stress level

1 — Low / calm10 — High / overwhelmed

How do you currently manage stress?

Section 4 — Lifestyle & daily habits

Describe your current physical activity

Describe your eating style and relationship with food

Foods avoided allergy, preference, or intolerance

Any digestive concerns? optional

How is your sleep quality?

Are you under a doctor's or mental health provider's care? if yes, briefly describe

Section 5 — Additional information

Are you experiencing stresses, mood conditions, or relationship difficulties for which you'd like a confidential referral? optional

Is there anything else about your health, life, or background that would be helpful for your coach to know? optional

How did you hear about this coaching practice?

Client acknowledgment

I understand that health and life coaching is not a substitute for professional medical or mental health treatment. The information provided is accurate to the best of my knowledge, and I agree to it being used to support my coaching experience. All information shared is strictly confidential and protected.

I have read and agree to the client acknowledgment above, and confirm the information I've provided is accurate to the best of my knowledge.

I confirm that I am 18 years of age or older.

Something went wrong. Please try again or contact your coach directly.

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Thank you, and welcome!

Your intake form has been received successfully.

Your coach will review everything before your first session and reach out shortly to confirm your appointment.

What happens next:
• Your coach will review your intake form
• You will receive a confirmation email shortly
• Your coach will reach out to confirm your first session

We are so excited to begin this journey with you.

— Health & Life Coaching