First Name
Last Name
Date of Birth
Gender
Phone Number
Email Address
Street Address
City/Suburb
State/Province
Zip/Postal Code
First Name
Last Name
Relationship
Phone Number
Do you have any chronic health conditions? (e.g., diabetes, hypertension, etc.)
If yes, please specify:
Are you currently under medical care or taking medications?
If yes, please specify:
How would you describe your current diet?
Balanced
Vegetarian/Vegan
High in processed foods
Other:
How often do you exercise?
Daily
3-5 times/week
Rarely
Never
Do you smoke
Do you consume alcohol?
Occasionally
Regularly
Never
How many hours of sleep do you get per night?
Less than 5
5-7
7-9
More than 9
On a scale of 1-10, how would you rate your stress levels? (1 = Low, 10 = High)
What are your primary sources of stress?
Work
Relationships
Finances
Health
Other:
What are your primary goals for lifestyle change? (Check all that apply)
Weight management
Improved nutrition
Increased physical activity
Stress reduction
Better sleep habits
Smoking cessation
Alcohol moderation
Work-life balance
Other:
What motivates you to make these changes?
Health concerns
Family or relationships
Personal fulfillment
Professional goals
Other:
Have you attempted lifestyle changes before?
If yes, what worked or didn’t work for you?
Please indicate your interest in the following programs:
Individual Coaching Programs:
One-on-One Personalized Coaching (Tailored to your specific goals)
Nutrition and Meal Planning Coaching
Fitness and Activity Coaching
Stress Management and Mindfulness Coaching
Sleep Optimization Coaching
Habit Formation and Behavior Change Coaching
Group Coaching Programs:
Group Weight Management Program
Group Fitness and Accountability Program
Stress Reduction and Mindfulness Group
Healthy Eating and Cooking Classes
Lifestyle Change Support Group
Other Options:
Hybrid Program (Combination of individual and group coaching)
Workshops or Seminars (e.g., stress management, nutrition basics)
How much time are you willing to dedicate to coaching each week?
Less than 1 hour
1-3 hours
3-5 hours
More than 5 hours
What is your budget for coaching services?
$0.00−$100.00/month
$100.00−$300.00/month
$300.00−$500.00/month
$500.00+/month
Do you prefer working independently or in a group setting?
Individual
Group
Both
What do you hope to gain from group coaching?
Accountability
Social Support
Shared Learning
Other:
How do you prefer to learn and receive information?
Visual (e.g., videos, diagrams)
Auditory (e.g., podcasts, discussions)
Kinesthetic (e.g., hands-on activities)
Reading/Writing (e.g., books, articles)
What challenges do you anticipate in achieving your goals?
Lack of time
Lack of motivation
Financial constraints
Other:
What support systems do you currently have in place?
Family
Friend
Healthcare provider
Other:
Are you comfortable using technology for coaching (e.g., apps, video calls)?
Do you have access to a smartphone, computer, and reliable internet?
Is there anything else you’d like us to know about you or your goals?
I understand that lifestyle change coaching is not a substitute for medical advice, diagnosis, or treatment.
I agree to take full responsibility for my health and well-being during the coaching process.
Signature
Client Intake Form Insights
Please remove this client intake form insights section before publishing.
This Client Intake Form is a comprehensive tool designed to gather critical information about a client’s current lifestyle, health status, goals, preferences, and challenges. Below is a detailed breakdown of the form’s sections, their purpose, and the insights they provide to a coach:
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This intake form is a powerful tool for building a strong coach-client relationship and ensuring the coaching process is effective, personalized, and aligned with the client’s needs.
To configure an element, select it on the form.