Kim Jandro - Home Life Coach, Emotional/Body Code Practitioner Services Wellness Coaching Integrative Wellness Coaching Form Scheduling Wellness FormsEvents Let’s Talk New Years ResolutionNatural WellnessAboutBlogsContact Integrative Wellness Coaching Welcome to Integrative Wellness Coaching (IWC). Please take a moment to thank yourself for showing up! At Integrative Wellness Coaching, we believe in the power of you and together, we will access your wisdom and energy to create steps that lead to change. The ultimate aim of IWC is to bring forth the path that leads to the best possible version of you. We work together to tap into your strengths. You will use those strengths to propel you into making conscious choices. In essence, we highlight your strengths, recognize areas for growth and potential, and provide an overall view of where you are right now and where you are headed. The information you provide will be strictly confidential manner, in compliance with HIPAA and professional ethics. The willingness to share pertinent information I useful in planning and an effective coaching plan. Fill in as much as you feel comfortable filling out, because it is a choice in the coaching process. Please keep in mind that health and wellness coaching is not a replacement for counseling or therapy. Name(Required) First Last Phone(Required)Email(Required) Preferred Contact? Email Phone Text Permission for messages be left on this phone?(Required) Yes No Birth Date MM slash DD slash YYYY Gender Ethnicity/Race Marital Status: Single Married/Living w/Partner Separated Divorced Widowed Do you have Children Yes No If yes, please list names and ages Do any live at home? Yes No Employment status General Health Allergies Medications Health Conditions (optional to disclose): Do you currently smoke or chew tobacco? Yes No If yes, packs per day Do you currently drink? Yes No If yes, how many days a week do you drink, and how many drinks per day? Please note anything that is important for your coach to know about your physical health. Energy Levels Please list Energy levels throughout a typical day; please include what gives you energy and what distracts and/or drains your energy. Please provide a work day and a non-work day. Examples of energy gains may be the ritual of coffee in the morning, seeing the kids off to school, having breakfast with a family member, walking your dog, going for a morning/afternoon/evening run. Spending time with loved ones, etc.…On a scale of 0-10 (0 being lowest and 10 being highest) share where you are at with your overall energy levels: Overall level of energy throughout the day (0-10): In few short sentences or words, share information about the following:Workday Energizers Workday energy drains Non-workday Energizers (if different from above) Non-workday drains (if different from above) Life SatisfactionOverall satisfaction in Life (0-10): In a word or sentence say more about the following areas of your life satisfaction: Sense of Purpose Joy Gratitude Work satisfaction Personal relationship satisfaction Anything else Mental (thoughts) and Emotional (feelings) being. Overall level of satisfaction in mental and emotional being (0-10): In a word or sentence say more about the following Coping skills (respond vs react, behaviors one adopts to deal with difficult situations) Resilience (ability to bounce back from rejection, missing deadlines, disappointment, etc.) Sleep patterns (consistency in sleep or not) Stress Levels Social activity/support Are you currently experiencing loss? Anything else? Body weight Overall level of satisfaction with body weight: (0-10) Physical movement and activity Overall level of satisfaction with movement and activity (0-10) Write a word or sentence for each category to provide more detail. Frequency (for example 2ce / week) Types (for example, walk dog) Duration (30 minutes) Anything else Nutrient intake Overall level of satisfaction in Nutrient intake: 0-10 Write a word or sentence in each category to provide more detail. Meal intake Frequency of snacks Types of snacks Fruit and vegetable intake Whole grain Water Soft drinks, Juice, smoothies, Caffeinated drinks Anything else Health factors/indicatorsOverall satisfaction of health factors (0-10) Please fill out to the best of your ability; if you do not know, just put don’t knowWomen’s/men’s health issues Personal/family health history Anything else Kim Jandro Emotion & Body Code Practitioner Contact Me
