Holistic Wellness Telehealth - Online Health Coaching Client Intake Form
I. Personal Information
First Name
Last Name
Date of Birth
Gender
Email Address
Phone Number
Mailing Address
Street Address
Street Address Line 2
City/Suburb
State/Province
Postal/Zip Code
Country
Preferred Method of Communication
Time Zone
Emergency Contact Name
Emergency Contact Phone Number
II. Health History
Please indicate your primary reason(s) for seeking health coaching. (Check all that apply)
Weight Management (Loss/Gain/Maintenance)
Dietary Changes
Increased Energy Levels
Stress Management
Improved Sleep
Enhanced Mental Wellbeing
Improved Physical Fitness
Chronic Disease Management
Other (Please specify):
If you select chronic disease management, please specify.
Current Health Concerns/Conditions: (Please list any diagnosed medical conditions, allergies, or sensitivities).
Current Medications/Supplements: (Please list all medications, vitamins, and supplements).
Past Medical History: (Please provide a brief overview of any significant past illnesses, surgeries, or hospitalizations).
Family Medical History: (Please list any significant health conditions that run in your family).
Current Primary Care Physician (PCP) Name and Contact Information.
Do you currently work with any other health professionals? (Therapist, nutritionist, etc.)
If yes, please list their names and specialties:
Are you currently experiencing any pain or discomfort?
If yes, please describe:
Have you experienced any recent significant life changes or stressors? (e.g., job change, relationship issues, loss of a loved one)
Have you ever been diagnosed with or treated for any mental health conditions? (Anxiety, depression, eating disorders, etc.)
III. Lifestyle Habits
Typical Daily Diet: Please describe what you typically eat in a day, including meals and snacks.
Please describe any Dietary Restrictions/Preferences (e.g., vegetarian, vegan, gluten-free, allergies).
Hydration Habits: (How much water do you drink daily?)
Sleep Habits: Please describe your typical sleep habits, including your typical bedtime, wake-up time, and overall sleep quality.
Stress Levels: (Rate your stress levels on a scale of 1-10, 1 being low, 10 being high)
Describe common stressors that trigger your stress.
Alcohol Consumption: Please describe your alcohol consumption in terms of frequency and amount.
Do you use Tobacco?
If yes, how often do you use tobacco, and what type do you use?
Caffeine Consumption: Please describe your caffeine consumption in terms of frequency and amount.
Do you engage in any mindfulness or relaxation practices? (Meditation, yoga, deep breathing, etc.)
IV. Goals and Expectations
What are your primary health and wellness goals? (Please be specific and measurable).
What are your expectations from this coaching program?
What does a "successful" outcome look like to you?
What are your biggest challenges in achieving your health goals?
What are your strengths and resources that will support your success?
What motivates you to make these lifestyle changes?
What are your time constraints and availability for coaching sessions?
What is your preferred method of accountability? (Check-ins, tracking, etc.)
What is your budget for this coaching program?
V. Suitability Assessment
Are you willing to commit to making consistent lifestyle changes?
Are you open to receiving guidance and feedback?
Are you comfortable with online communication and technology?
Do you understand that health coaching is not a substitute for medical advice?
Are you currently experiencing any severe mental health symptoms that require immediate professional intervention?
Do you have any eating disorders that require professional treatment from a medical professional?
Are you currently under the care of a physician for any diagnosed medical condition?
If yes, have you discussed your intention to begin a health coaching program with them?
Do you understand that this coaching program focuses on lifestyle changes and not medical diagnosis or treatment?
Do you understand that the responsibility of your health is ultimately your own, and that the coach provides support and guidance?
Are you willing to sign a client agreement outlining the terms and conditions of the coaching program?
VI. Additional Information
Anything else you would like to share with your coach?
Client Signature:
Form Template Insights
Form Template Insights
Please remove this Form template insight section before publishing.
Important Considerations for Suitability:
- Mental Health: If a client indicates severe mental health symptoms or an eating disorder, it's crucial to refer them to a licensed mental health professional or medical doctor.
- Medical Conditions: If a client has a diagnosed medical condition, ensure they have discussed the coaching program with their physician.
- Client Expectations: Clarify the scope of coaching and ensure the client understands it's not a substitute for medical advice.
- Client Commitment: Assess the client's willingness to commit to lifestyle changes.
- Safety and Ethical Considerations: Prioritize client safety and adhere to ethical guidelines.
This detailed intake form will help you gather essential information and determine if your coaching program is a good fit for each client. Remember to review the form thoroughly and discuss any concerns with the client during your initial consultation.
Client Intake Form Insights:
Let's break down the client intake form section by section, providing detailed insights into its purpose and the importance of each question:
Section 1: Personal Information
Purpose: Establishes basic contact information, demographics, and preferred communication methods.
Insights:
- Accurate contact information is crucial for communication and scheduling.
- Knowing the client's time zone is essential for telehealth appointments.
- Emergency contact information is vital for safety.
- Understanding how the client found your program helps with marketing analysis.
- The gender question should always contain a "prefer not to say" option, or an option to write in a gender, to be respectful of everyones identity.
Section 2: Health History
Purpose: Gathers information about the client's current and past health, which is crucial for understanding their needs and potential limitations.
Insights:
- Identifying primary reasons for seeking coaching helps tailor the program.
- Detailed medical history is essential for identifying potential risks and contraindications.
- Medication and supplement information is vital for avoiding interactions and understanding potential side effects.
- Family medical history can reveal genetic predispositions.
- Knowing about current pain or discomfort helps avoid exacerbating existing issues.
- The questions about mental health are very important. If a client is experiencing severe mental health issues, those issues must be addressed by a medical professional before lifestyle coaching can be effective.
- Knowing if they are working with other health professionals allows for better collaboration, if the client wishes for that collaboration.
Section 3: Lifestyle Habits
Purpose: Provides a comprehensive overview of the client's current lifestyle, including diet, exercise, sleep, and stress levels.
Insights:
- Understanding dietary habits helps identify areas for improvement.
- Assessing exercise routines helps determine appropriate fitness goals.
- Evaluating sleep patterns is crucial for overall well-being.
- Identifying stress levels and stressors helps develop stress management strategies.
- Information about alcohol, tobacco, and caffeine use helps assess potential health risks.
- Knowing if they practice mindfulness gives insight into their current coping mechanisms.
Section 4: Goals and Expectations
Purpose: Clarifies the client's goals, expectations, and motivations, which are essential for creating a successful coaching relationship.
Insights:
- Specific and measurable goals provide a clear roadmap for progress.
- Understanding client expectations helps manage expectations and avoid misunderstandings.
- Identifying challenges and strengths helps develop personalized strategies.
- Understanding client motivation is crucial for maintaining engagement.
- Time constraints and budget information help tailor the program to the client's needs.
- Preferred accountability methods help ensure client compliance.
Section 5: Suitability Assessment
Purpose: Determines if the coaching program is a good fit for the client and if they are ready to commit to making lifestyle changes.
Insights:
- Assessing client commitment and openness to feedback is crucial for success.
- Ensuring the client understands the scope of coaching and its limitations is essential for ethical practice.
- Identifying potential red flags, such as severe mental health symptoms or eating disorders, helps ensure client safety.
- Obtaining client agreement on the terms and conditions of the program helps establish clear boundaries.
- This section is very important for liability concerns.
- It is important to ensure that the client understands that the coach is not a medical professional, and that the client is responsible for their own health.
Section 6: Additional Information (Optional)
Purpose: Provides an opportunity for the client to share any additional information that may be relevant to their coaching.
Insights:
- This section allows for open communication and can reveal important information that may not have been covered in previous sections.
Key Takeaways:
- Thoroughness: The form is designed to gather comprehensive information, which is essential for providing effective coaching.
- Client-Centered Approach: The questions are designed to understand the client's needs, goals, and preferences.
- Safety and Ethical Considerations: The form includes questions to assess potential risks and ensure ethical practice.
- Clarity and Transparency: The form helps establish clear expectations and avoid misunderstandings.
- Legal Protection: The form helps to protect the coach legally by documenting the clients understanding of the coaching process.
- Adaptability: This form can be adapted to fit the specific needs of your coaching program and target audience.
By carefully reviewing and analyzing the information gathered from this intake form, you can develop a personalized coaching program that empowers your clients to achieve their health and wellness goals.
To configure an element, select it on the form.