Client Intake Form Template for Health & Wellness Coaching

Use in FirstRep form

Personal Information

Collecting personal information helps tailor the coaching experience to individual needs.

Aa Full Name *

John Doe

Aa Email Address *

[email protected]

Aa Phone Number

(123) 456-7890

Health Background

Understanding your health history allows for a more effective coaching plan.

Y/N Do you have any chronic conditions? *

... List any medications you are currently taking

e.g., Blood pressure medication

Y/N Have you had any surgeries in the past?

Lifestyle Assessment

Assessing your lifestyle habits helps identify areas for improvement.

# How many hours do you sleep per night? *

e.g., 7

1-10 Rate your stress level from 1 to 10 *

# How many servings of fruits/vegetables do you consume daily? *

e.g., 5

Goals and Motivation

Clarifying your goals helps in creating a focused wellness plan.

... What are your primary health goals? *

e.g., Lose weight, lower blood pressure

... What motivates you to achieve these goals? *

e.g., Family, health

... What barriers do you face in reaching your goals? *

e.g., Time, support

Accountability and Support

Understanding your support system can enhance accountability.

Y/N Do you have a support system in place? *

v How often do you want to check in with your coach? *

... What tools do you currently use for tracking your health?

e.g., Apps, journals

Holistic Wellness Dimensions

Exploring various dimensions of wellness ensures a comprehensive approach.

1-10 Rate your physical wellness from 1 to 10 *

1-10 Rate your emotional wellness from 1 to 10 *

1-10 Rate your social wellness from 1 to 10 *

Why Use This Template

Personalized Coaching

Customizing your plan based on your unique needs.

Goal Clarity

Ensuring your health goals are clearly defined.

How to Use

Fill out each section carefully to provide comprehensive information.

Submit the form to your coach for review and discussion.

Customization Tips

Add specific questions related to your coaching style.
Include optional fields for additional health assessments.
Tailor the language to match your brand voice.

Build and send health & wellness coaching templates digitally with FirstRep. Free for up to 3 clients.

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Frequently Asked Questions

What if I don't have a chronic condition?

This form is for all individuals seeking wellness, regardless of health status.

Can I save my progress?

Unfortunately, the form does not support saving progress; please complete it in one sitting.