NEW CLIENT FORM

Please complete the following form at least 48 hours prior to our first coaching session so I have sufficient time for review. We will use this information as a basis for our initial conversation. I will also ask more specific questions regarding your health and medical history during our live session.

Name

First Name

Last Name

Email

Preferred Pronouns

Date of Birth

MM

DD

YYYY

What are your current health, wellness, and/or fitness goals?

Please list any other professionals you are working with right now on your health, wellness, and/or fitness (e.g. medical doctor, other physician or specialist, therapist, personal trainer, other practitioner).

Please list any supplements or medications you are currently taking.

Do you experience any pain, stiffness, or swelling on a regular basis? If so, please explain.

How would you describe your history and current relationship with food?

Do you follow any specific eating approaches/practices for personal, health, or religious reasons? If so, please explain.

What does a typical day of eating look like for you? List a few foods/meals and drinks you usually consume.

How would you describe your current routine with movement in your daily and/or weekly life, including sports, exercise, and other types of activity?

What are the most influential relationships in your life currently?

How would you describe your overall mental and emotional health?

What role does spirituality and/or religion play in your life, if any?

The security of your information is important to Janessa Nickell, LLC, but remember that no method of transmission over the internet, or method of electronic storage, is 100% secure. While Janessa Nickell, LLC strives to use commercially acceptable means to protect your personal information, Janessa Nickell, LLC cannot guarantee its absolute security. By submitting this form, you acknowledge and accept these risks.

JANESSA NICKELL

NEW CLIENT FORM