Discovery Form

Please complete the following form with as much detail as you are comfortable sharing. This will enable me to better understand your current health goals in advance of our Discovery Call so I can properly prepare.

Personal Information

Name *

First

Last

Email *

Phone

Age *

Main Health Goals

Why are you reaching out to a health coach? What specific health, wellness, and lifestyle changes would you like to make? Please rate each of your goals on a scale of 1-10, how important is each of these desired changes that you would like to make?

Must fill in at least one Health Goal. 1 = not very important, 10 = non-negotiable.

Health Goal *

Rating *

Health Goal 2

Rating 2

Health Goal 3

Rating 3

Health Goal 4

Rating 4

Health Goal 5

Rating 5

Health Goal 6

Rating 6

How would life be different if you were to achieve your health goals? *

What have been the barriers in preventing you from already achieving these goals yourself? *

How do you feel a Health Coach will help you achieve your goals? *

Coachability Self-Assessment

One a scale of 1-10, rate how ready you are to begin a health coaching relationship right now.

1 = Not ready at all, 5 = I think I’m ready, 10 = I am 100% ready and excited!

I am open to learning new ways to eat, move and generally live. *

1	2	3	4	5	6	7	8	9	10
1I am open to learning new ways to eat, move and generally live. 1	2I am open to learning new ways to eat, move and generally live. 2	3I am open to learning new ways to eat, move and generally live. 3	4I am open to learning new ways to eat, move and generally live. 4	5I am open to learning new ways to eat, move and generally live. 5	6I am open to learning new ways to eat, move and generally live. 6	7I am open to learning new ways to eat, move and generally live. 7	8I am open to learning new ways to eat, move and generally live. 8	9I am open to learning new ways to eat, move and generally live. 9	10I am open to learning new ways to eat, move and generally live. 10

I can commit to changes that may feel uncomfortable, unusual or unconventional. *

1	2	3	4	5	6	7	8	9	10
1I am open to learning new ways to eat, move and generally live. 1	2I am open to learning new ways to eat, move and generally live. 2	3I am open to learning new ways to eat, move and generally live. 3	4I am open to learning new ways to eat, move and generally live. 4	5I am open to learning new ways to eat, move and generally live. 5	6I am open to learning new ways to eat, move and generally live. 6	7I am open to learning new ways to eat, move and generally live. 7	8I am open to learning new ways to eat, move and generally live. 8	9I am open to learning new ways to eat, move and generally live. 9	10I am open to learning new ways to eat, move and generally live. 10

I will communicate and negotiate with my coach as an equal partnership and feel confident to express myself and ask for what I need. *

1	2	3	4	5	6	7	8	9	10
1I am open to learning new ways to eat, move and generally live. 1	2I am open to learning new ways to eat, move and generally live. 2	3I am open to learning new ways to eat, move and generally live. 3	4I am open to learning new ways to eat, move and generally live. 4	5I am open to learning new ways to eat, move and generally live. 5	6I am open to learning new ways to eat, move and generally live. 6	7I am open to learning new ways to eat, move and generally live. 7	8I am open to learning new ways to eat, move and generally live. 8	9I am open to learning new ways to eat, move and generally live. 9	10I am open to learning new ways to eat, move and generally live. 10

I have a high level of self awareness. *

1	2	3	4	5	6	7	8	9	10
1I am open to learning new ways to eat, move and generally live. 1	2I am open to learning new ways to eat, move and generally live. 2	3I am open to learning new ways to eat, move and generally live. 3	4I am open to learning new ways to eat, move and generally live. 4	5I am open to learning new ways to eat, move and generally live. 5	6I am open to learning new ways to eat, move and generally live. 6	7I am open to learning new ways to eat, move and generally live. 7	8I am open to learning new ways to eat, move and generally live. 8	9I am open to learning new ways to eat, move and generally live. 9	10I am open to learning new ways to eat, move and generally live. 10

I will keep my word to my coach and myself. *

1	2	3	4	5	6	7	8	9	10
1I am open to learning new ways to eat, move and generally live. 1	2I am open to learning new ways to eat, move and generally live. 2	3I am open to learning new ways to eat, move and generally live. 3	4I am open to learning new ways to eat, move and generally live. 4	5I am open to learning new ways to eat, move and generally live. 5	6I am open to learning new ways to eat, move and generally live. 6	7I am open to learning new ways to eat, move and generally live. 7	8I am open to learning new ways to eat, move and generally live. 8	9I am open to learning new ways to eat, move and generally live. 9	10I am open to learning new ways to eat, move and generally live. 10

I understand that a health coach is an investment in myself and will not suffer with the finical costs. *

1	2	3	4	5	6	7	8	9	10
1I am open to learning new ways to eat, move and generally live. 1	2I am open to learning new ways to eat, move and generally live. 2	3I am open to learning new ways to eat, move and generally live. 3	4I am open to learning new ways to eat, move and generally live. 4	5I am open to learning new ways to eat, move and generally live. 5	6I am open to learning new ways to eat, move and generally live. 6	7I am open to learning new ways to eat, move and generally live. 7	8I am open to learning new ways to eat, move and generally live. 8	9I am open to learning new ways to eat, move and generally live. 9	10I am open to learning new ways to eat, move and generally live. 10