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WILD & WELL
ADVENTURES
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Background Intake Form
First name
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Last name
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Email
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Phone
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Birthday
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Month
Month
Day
Year
Occupation
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Background and Current Situation
What inspired you to seek coaching at this time, and have you worked with a coach before? If so, what was your experience?
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What areas of your life need the most attention (e.g., health, relationships, career, personal growth)?
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How would you rate your overall well-being on a scale of 1-10? What factors influence this rating?
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What are the top three stressors or challenges you’re facing at the moment?
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Goals and Aspirations
What specific goals do you hope to achieve through coaching?
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Where do you see yourself in 6 months to a year?
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What would achieving your goals feel like or look like in your daily life?
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What challenges might arise, and how do you envision overcoming them?
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Health and Wellness
Do you have a regular self-care routine? If yes, what does it involve?
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How would you describe your current physical health?
Do you incorporate mindfulness or meditation into your day? If yes, what does this look like?
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How do you typically handle stress or navigate difficult emotions?
Yoga and Mindfulness
Have you practiced yoga or mindfulness before? If so, what was your experience?
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What draws you to yoga or mindfulness, and how do you hope it will support your journey?
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Are there specific yoga practices or philosophies that resonate with you?
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Personal Journey and Transformation
What areas of your life do you feel most need transformation or support?
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Have significant life events impacted your health and well-being?
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What would that look and feel like if you were living your most vibrant and balanced life?
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Are there habits or behaviors you wish to change or improve?
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What energizes you and gets you into a state of "flow"?
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What drains your energy or leaves you feeling depleted?
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How do you feel about your relationships and the people you surround yourself with?
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How satisfied are you with your contribution and value to the world?
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On a scale of 1-10, how would you rate:
Acting with focus and direction versus floating through your day?
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Feeling connected to others in your life?
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Your personal development and readiness for change?
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Commitment and Expectations
What motivates you to embark on this journey, and how can I best support you to ensure you feel guided and empowered throughout the process?
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How much time and energy are you willing to invest in your personal development?
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Additional Information
Is there anything else you’d like me to know so I can better support you?
Do you have any questions or concerns about the coaching process?
Consent and Agreement
I agree to the terms and conditions of the coaching agreement
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Yes
No
I understand that coaching is not a substitute for professional medical advice, diagnosis, or treatment
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Yes
No
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