🌿 SIMPLY MINDFUL – CLIENT INTAKE FORM
(For Use in Product Add-On Form at Checkout)
✨ SECTION 1 — PERSONAL INFORMATION
Full Name
Short answer
Email Address
Email field
Phone Number
Short answer
Preferred Contact Method
Dropdown
• Email
• Text
• Phone Call
✨ SECTION 2 — AVAILABILITY
Preferred Days for Sessions
Checkboxes (allow multiple)
• Monday
• Tuesday
• Wednesday
• Thursday
• Friday
• Saturday
Preferred Time of Day
Dropdown
• Morning
• Afternoon
• Evening
✨ SECTION 3 — YOUR WELLNESS GOALS
What made you want to start this coaching journey?
Long answer (or short answer if long isn't allowed)
What are your top 3 wellness goals?
Short answer or long answer
What areas of your life feel out of balance?
Checkboxes
• Emotional
• Physical
• Spiritual
• Mental
• Lifestyle / Habits
• All of the above
Have you ever done coaching before?
Dropdown
• Yes
• No
✨ SECTION 4 — PERSONAL NEEDS / SUPPORT
How would you describe your current emotional state?
Dropdown
• Calm
• Overwhelmed
• Anxious
• Grieving
• Searching for direction
• Hopeful
• Other
Is there anything I should know to support you better?
Long answer
✨ SECTION 5 — AGREEMENTS
I understand this is a non-refundable program.
Checkbox (required)
I agree to show up for sessions on time and communicate if I need to reschedule.
Checkbox (required)
I understand this is not therapy or medical treatment.
Checkbox (required)
I have read and agree to the Simply Mindful Coaching Agreement.
Checkbox (required)
🌸 SECTION 6 — FINAL CONFIRMATION
How ready do you feel to begin this journey?
Dropdown
• 100% ready
• Nervous but ready
• Excited
• Unsure, but willing to try
Anything else you wish to share before our first call?
Short or long answer

