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Better Health through Better Living

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470-861-6050
info@mycareplushealth.org
United States

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Client Intake Form

CarePlus Health is happy to welcome you as a new client. We are excited that you chose us to help you achieve your personal health and wellness goals. Please complete the following information:

Individual Client

Corporate Client

Contact Information

Coaching Type

Diabetes

Cholesterol

Health/Wellness

Other (explain)

Health Record

Cholesterol profile

Disclaimer

(Client initials)

The Client is aware that the coaching relationship does not represent psychological counseling or any kind of therapy.

The Client is also aware that coaching results can vary and are not guaranteed.

The Client agrees that they are entering into coaching with the understanding that the Client is responsible for their own decisions and results.

The client understands that all written and oral information disclosed will remain confidential.

The Client also agrees to hold the Nurse Health Coach free from all liability for any actions or results for adverse situations created as a direct or indirect result of advice given by the Nurse Health Coach.

Session Contact Procedure

The Client shall be available and responsive at the agreed hour.

If the Client fails to make the appointment time, the Client is still responsible for the coaching fee, unless 24 hours notice was given to reschedule the call.

The Nurse Coach will make every effort to reschedule with the Client.

Important Issues

Please briefly outline any issues you would like to deal with and what you hope to achieve in the health coaching setting.

Issue #1

Issue #2

Issue #3

Issue #4

Personal Profile

Please answer the following to let us get to know you a bit better.

I would describe myself as:

Others would describe me as:

The three things that I like most about my life/situation are

If I could change three things about my life/situation, they would be:

My three greatest accomplishments (so far) are:

Some of my hobbies/interests are:

The one thing I would like most to accomplish (but haven’t yet) is:

The one thing I wish I could change in the short-term is:

I think that the most important thing in life is:

I am interested in working with a health coach because: