Lifestyle Change Coaching Client Intake Form

I. Client Information

First Name

Last Name


Date of Birth

Last Name

Email Address

Street Address

City/Suburb

State/Province

Postal/Zip Code


Preferred Method of Communication

Occupation

II. Current Lifestyle and Goals

What areas of your lifestyle are you looking to change? (Check all that apply)

What are your primary goals for working with a lifestyle change coach?

What are your top 3 priorities for change?

On a scale of 1-10, how committed are you to making these changes? (1 = Not Committed, 10 = Extremely Committed)

What challenges have you faced in the past when trying to make lifestyle changes?

What are your current daily habits related to: Nutrition (Typical meals, snacks, dietary restrictions, etc.)

What are your current daily habits related to: Fitness (Current activity level, types of exercise, frequency, etc.)

What are your current daily habits related to: Sleep (Average hours of sleep, sleep quality, bedtime routine, etc.)

What are your current daily habits related to: Stress Management (How do you currently manage stress?)

Do you have any current health conditions or medical concerns? (Please list)

Are you currently taking any medications? (Please list)

Do you have any food allergies or sensitivities?

What does your ideal day look like?

III. Program Options and Suitability

Program Options

Individual Coaching Programs:

"Foundations for Change" (3-Month Program):

  • Focus: Establishing core habits, goal setting, personalized action plans.
  • Includes: Weekly 1:1 coaching sessions, personalized resources, email support.

"Transform Your Lifestyle" (6-Month Program):

  • Focus: Deep dive into lifestyle transformation, advanced habit building, ongoing support.
  • Includes: Bi-weekly 1:1 coaching sessions, personalized resources, email and text support, progress tracking.

"Premium Personalized Coaching" (12-Month Program):

  • Focus: complete lifestyle overhaul, intensive support, and long-term sustainable change.
  • Includes: Weekly 1:1 coaching sessions, 24/7 access to coach, personalized resources, meal planning and fitness plan creation, progress tracking, and regular evaluation.


Group Coaching Programs:

"Healthy Habits Group" (8-Week Program):

  • Focus: Building foundational healthy habits in a supportive group environment.
  • Includes: Weekly group sessions, group challenges, shared resources, online community.

"Mindful Living Group" (10-Week Program):

  • Focus: Stress reduction, mindfulness practices, and emotional well-being.
  • Includes: Weekly group sessions, guided meditations, mindfulness exercises, online community.

"Fitness and Nutrition Group" (12-Week Program):

  • Focus: Combined fitness and nutrition guidance, group workouts, meal planning support.
  • Includes: Weekly group workouts and sessions, meal planning resources, online community.

Suitability Questions

Which of the above program options are you most interested in? (Please list 1-2)

Why are you interested in this/these particular program(s)?

Are you more comfortable with individual or group coaching?

What is your preferred method of learning and support? (e.g., visual, auditory, hands-on, written, etc.)

How much time per week are you willing to dedicate to your lifestyle change goals?

What is your budget for coaching services?

For Group Coaching:

Are you comfortable sharing your experiences and goals with a group?

Do you enjoy learning and being motivated by others?

For Individual Coaching:

Do you prefer personalized attention and a tailored approach?

Do you prefer to work through your challenges one on one?

Additional Information

Is there anything else you would like to share with me that you feel is relevant to your coaching journey?

Agreement and Consent

I understand that coaching is not a substitute for medical or psychological advice.

I agree to be honest and open with my coach throughout the coaching process.

I understand that all information shared with my coach will be kept confidential, except as required by law.

I agree to the terms and conditions outlined in the coaching agreement.

Signature


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