New Client Form — Shawnna Health Coach

Congratulations! You’ve decided to take the next steps to living a Balanced & better life.

I am so excited to spend the next three months with you. Together, we will work towards enhancing the better aspects of your life and eliminating things that leave you feeling drained and unworthy—a happier, healthier you is on the way!

Please take several minutes to complete the New Client Intake Form, and let’s get started!

New Client Intake Form

Name

First Name

Last Name

Date of Birth

YYYY

Gender Identity

Phone

(###)

###

####

Preferred Method of Contact

Text

Phone Call

Emergency Contact

First Name

Last Name

Phone

(###)

###

####

Occupation

Briefly describe your current health concerns

Do you have any significant past medical history or medical diagnoses?

Please list any medications or supplements

Please describe your current physical activity level

Please describe your typical nutritional intake

How often do you consume alcohol?

Any recreational drug use?

What challenges have you encountered that prevented you from reaching your health goals?

What are your short term health goals? (3 Months)

What are your long term health goals? (5 years)

What do you value most in life?

Describe what role (if any) religion and/or spirituality plays in your life

Where do you see yourself when this coaching session is over?

What additional information would you like your coach to know?

Congratulations! You’ve decided to take the next steps to living a Balanced & better life.

Thank you!