Wellness Coaching Intake
Holistic intake form for wellness coaching covering physical health, mental wellbeing, and lifestyle factors.
Template Content
WELLNESS COACHING INTAKE FORM
PERSONAL INFORMATION
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Name: _________________________
Age: _________________________
Email: _______________________
Phone: ______________________
Emergency Contact: ____________
Preferred Communication: ☐ Email ☐ Phone ☐ Text
CURRENT HEALTH STATUS
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1. Please describe your current overall health:
☐ Excellent ☐ Very good ☐ Good ☐ Fair ☐ Poor
2. Do you have any current health conditions or concerns?
☐ Yes ☐ No
If yes, please describe: _________________
3. Are you currently taking any medications or supplements?
☐ Yes ☐ No
If yes, please list: ____________________
[Form continues with physical wellness, mental/emotional wellness, lifestyle habits, wellness goals, motivation assessment, support systems, and coaching preferences]
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