First Name
Last Name
Date of Birth
Gender
Phone Number
Email Address
Mailing Address
Last Name
Last Name
Last Name
Emergency Contact Name
Emergency Contact Phone
What are your primary wellness goals? (Check all that apply)
Weight Management
Improved fitness and strength
Stress reduction and relaxation
Better sleep quality
Enhanced mindfulness and mental clarity
Improved nutrition and eating habits
Chronic pain management
Emotional well-being and balance
Other (Please specify):
On a scale of 1-10, how would you rate your current level of satisfaction with your overall wellness? (1 = Very Dissatisfied, 10 = Very Satisfied)
Your Overall Wellness | Rating (1 = Very Dissatisfied, 10 = Very Satisfied) | |
|---|---|---|
Physical Health | ||
Mental Health | ||
Emotional Health | ||
Spiritual Health |
What specific outcomes are you hoping to achieve through this program?
Do you have any pre-existing medical conditions or diagnoses?
Are you currently taking any medications or supplements?
Have you had any surgeries or hospitalizations in the past 5 years?
Do you have any allergies or sensitivities?
Do you experience any chronic pain or physical limitations?
How would you describe your current activity level?
Sedentary (little to no exercise)
Lightly Active (light exercise 1-2 days/week)
Moderately Active (moderate exercise 3-5 days/week)
Very Active (intense exercise 6-7 days/week)
What is your typical daily diet like?
Balanced and healthy
Mostly healthy with occasional indulgences
Inconsistent or unbalanced
Other (Please specify):
Do you consume alcohol, tobacco, or recreational drugs?
How many hours of sleep do you get on average per night?
Less than 5 hours
5-7 hours
7-9 hours
More than 9 hours
Do you practice any mindfulness or stress-management techniques?
Which wellness modalities are you most interested in? (Check all that apply)
Fitness (e.g., yoga, strength training, cardio)
Nutrition (e.g., meal planning, dietary guidance)
Mindfulness (e.g., meditation, breathwork)
Stress Management (e.g., relaxation techniques, time management)
Sleep Improvement (e.g., sleep hygiene, relaxation practices)
Emotional Well-being (e.g., counseling, journaling)
Spiritual Growth (e.g., mindfulness, self-reflection)
Other (Please specify):
Have you participated in any wellness programs before?
What is your preferred method of communication for wellness coaching?
Video Calls
Phone Calls
Messaging/Chat
How much time can you realistically dedicate to wellness activities each week?
Less than 1 hour
1-3 hours
3-5 hours
More than 5 hours
Do you have any preferences for the timing of sessions (e.g., mornings, evenings)?
Are there any cultural, religious, or personal considerations we should be aware of when designing your program?
What motivates you to make positive changes in your life?
What challenges or barriers do you anticipate in achieving your wellness goals?
I understand that this program is designed to support my wellness goals and is not a substitute for medical advice or treatment.
I agree to provide accurate and honest information to ensure the best possible support.
I consent to the use of my information for the purpose of designing and delivering my wellness program.
Client Signature
Client Intake Form Insights
Please remove this client intake form insights section before publishing.
Below is a detailed breakdown of the Holistic Wellness Telehealth - Online Wellness Programs Client Intake Form, including insights into its purpose, structure, and the significance of each section. This form is designed to gather comprehensive information about the client to ensure personalized and effective wellness programming.
The primary goal of this form is to:
This Holistic Wellness Telehealth Client Intake Form is a powerful tool for both clients and providers. It ensures that wellness programs are safe, personalized, and aligned with the client’s goals and preferences. By gathering detailed information upfront, providers can deliver more effective and meaningful support, while clients can feel confident that their unique needs are being addressed.