Before we begin

Client intake and well-being assessment.

One form, two parts: a little about you and your health history, then your Well-Being Wheel of Life. It takes around 10 minutes, and it means your first session starts exactly where you are.

Private

Goes only to Lisa

10 minutes

Answer what feels right

No judgement

A safe place to be honest

Contact information

So I can reach you, and someone close to you if ever needed.

Full name

Date of birth

Gender

Email address

Mobile phone

Preferred language

Emergency contact

Emergency contact number

Your aspirations and goals

There are no wrong answers here.

What are you hoping to get out of coaching?

How would you like your habits or health to be different?

Health and wellbeing

Share what feels relevant. Coaching is guidance and support, not medical care.

What health problems or diagnoses have you been informed of?

What medications are you taking? (prescription and over the counter)

What supplements are you taking?

Energy level (1 to 10)

Stress level (1 to 10)

How do you manage stress?

How would you describe your physical activity and movement?

Frequency, types, duration, and how you feel about it.

How would you describe your eating style?

Any foods you avoid, whether by preference, allergy or intolerance?

How would you describe your relationship with food?

Do you experience regular gas, constipation, diarrhea, bloating, nausea or heartburn?

Care and support

Optional, and always confidential.

Are you currently under the care of a doctor or a mental health provider? If yes, please describe briefly.

Are you experiencing anything you'd like resources or a confidential referral for?

For example stress, mood, relationships, or substance related concerns.

Is there anything else about your health history I should know?

Empowered Well-Being Wheel of Life

Taking the centre as 0 and the outer edge as 10, rate your satisfaction with each area. Your wheel draws itself as you go.

Is it a smooth ride, or a bumpy one? Which areas are strong, and which could use attention?

Physical5/10

Energy, movement, sleep, nourishment

Environmental5/10

Home, workspace, the spaces you spend time in

Mental5/10

Focus, clarity, learning, self-talk

Emotional5/10

Feelings, regulation, resilience

Spiritual5/10

Meaning, purpose, connection to something larger

Social5/10

Relationships, community, belonging

Vocational5/10

Work, calling, contribution

Financial5/10

Stability, confidence with money

Looking at your wheel, what stands out? Where would you like to begin?

I'm happy for Lisa to read this and use it to prepare our work together. I understand coaching is guidance and support, and does not replace medical or mental health care.

Your answers go only to Lisa.