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New Client Intake Form

Welcome! Please complete this form before your first session.
All information is kept strictly confidential.

Step 1 of 5

📋 Section 1

Demographics & Contact Information

Let's start with some basic information so we can get to know you.

First Name *

Last Name *

Date of Birth *

Biological Sex

Gender Identity

Email Address *

Phone Number *

Address

Preferred Pronouns

Preferred Session Format

Emergency Contact Name

Emergency Contact Phone

How did you hear about us?

🏥 Section 2

Health History & Medications

Understanding your health background helps us tailor your coaching plan safely and effectively.

Chronic Conditions

Check all that apply:

Type 2 Diabetes Pre-Diabetes Hypertension High Cholesterol Heart Disease / CVD Obesity Metabolic Syndrome Thyroid Disorder Autoimmune Condition PCOS Osteoporosis / Osteopenia Anxiety / Depression Sleep Disorder Cancer (history or current)

Other conditions not listed above

Current Medications & Supplements

Prescription Medications

Supplements & Over-the-Counter

Medical Team

Primary Care Provider

Relevant Specialists

May we communicate with your healthcare provider(s) if needed?

Yes No Ask me first

Any recent labs, diagnoses, or health concerns we should know about?

🌱 Section 3

Lifestyle Factors

Lifestyle is the foundation of health. Help us understand your current patterns across key pillars.

🥗 Nutrition

How would you describe your current eating pattern?

Meals eaten per day (avg)

Glasses of water per day (avg)

Food allergies or intolerances

Biggest nutritional challenges

🏃 Physical Activity

Days of moderate exercise per week

Avg session duration

Types of physical activity you enjoy or currently do

Physical limitations or injuries

😴 Sleep

Average hours of sleep per night

Sleep quality

Sleep challenges (check all that apply)

Difficulty falling asleep Waking during the night Early morning waking Feeling unrested upon waking Snoring / Sleep apnea No significant issues

🧘 Stress & Mental Wellbeing

Current stress level (1 = minimal, 10 = extreme)

1 – Minimal10 – Extreme

Current stress management practices

Meditation / Mindfulness Exercise / Movement Journaling Therapy / Counseling Deep breathing Nature / Outdoor time Social support None currently

🚭 Substance Use

Tobacco / Nicotine use

Alcohol consumption

🎯 Section 4

Health Goals & Motivation

This is what coaching is all about. Let's clarify where you want to go and what drives you.

Primary reason for seeking health coaching today *

Top health goals (check up to 3)

Manage / reverse a chronic condition Lose weight Improve energy levels Reduce medications Improve nutrition habits Build a consistent exercise routine Improve sleep quality Reduce / manage stress Improve mental wellbeing Prevent future disease Improve longevity & healthspan Prepare for or recover from a procedure

What does success look like to you in 6 months?

What has gotten in the way of your health goals in the past?

Readiness to make lifestyle changes (1 = not ready, 10 = fully committed)

1 – Not ready10 – Fully committed

Preferred coaching communication style

Best time to reach you

Anything else you'd like your coach to know?

📝 Section 5

Consent & Privacy Acknowledgment

Please read and sign the following agreements before we begin our work together.

Scope of Practice Acknowledgment
Health and wellness coaching is a collaborative, client-centered process focused on supporting lifestyle behavior change. Coaching is not a substitute for medical care, diagnosis, or treatment. Your coach is a National Board Certified Health & Wellness Coach (NBC-HWC) and may hold credentials in lifestyle medicine, but does not provide medical advice, prescribe treatments, or diagnose conditions.

Confidentiality & Privacy
All information shared in coaching sessions and on this form is held in strict confidence, consistent with applicable privacy regulations. Information will not be shared with third parties without your written consent, except where required by law (e.g., imminent risk of harm).

Session Policies
Sessions are scheduled in advance. Please provide at least 24 hours' notice for cancellations or rescheduling. Late cancellations or no-shows may be subject to a fee per our agreement. You may discontinue coaching at any time.

I understand that health coaching is not medical care and does not replace the advice of a physician or other licensed healthcare provider. I consent to participate in health and wellness coaching and understand that I am responsible for my own health decisions. I have read and agree to the confidentiality, privacy, and session policies described above. I consent to my coach sharing de-identified, aggregate information for program improvement or educational purposes.

Electronic Signature (Full Legal Name) *

Date *

✓

Thank you for completing your intake!

Your information has been received. Your coach will review your responses and reach out before your first session to confirm details and answer any questions.

We're excited to support you on your health journey. 🌿

Full Spectrum Human

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