πΏ SIMPLY MINDFUL β CLIENT INTAKE FORM
(For Use in Product Add-On Form at Checkout)
β¨ SECTION 1 β PERSONAL INFORMATION
Full Name
Short answer
Email Address
Email field
Phone Number
Short answer
Preferred Contact Method
Dropdown
β’ Email
β’ Text
β’ Phone Call
β¨ SECTION 2 β AVAILABILITY
Preferred Days for Sessions
Checkboxes (allow multiple)
β’ Monday
β’ Tuesday
β’ Wednesday
β’ Thursday
β’ Friday
β’ Saturday
Preferred Time of Day
Dropdown
β’ Morning
β’ Afternoon
β’ Evening
β¨ SECTION 3 β 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
β’ Emotional
β’ Physical
β’ Spiritual
β’ Mental
β’ Lifestyle / Habits
β’ All of the above
Have you ever done coaching before?
Dropdown
β’ Yes
β’ No
β¨ SECTION 4 β PERSONAL NEEDS / SUPPORT
How would you describe your current emotional state?
Dropdown
β’ Calm
β’ Overwhelmed
β’ Anxious
β’ Grieving
β’ Searching for direction
β’ Hopeful
β’ Other
Is there anything I should know to support you better?
Long answer
β¨ SECTION 5 β 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)
πΈ SECTION 6 β FINAL CONFIRMATION
How ready do you feel to begin this journey?
Dropdown
β’ 100% ready
β’ Nervous but ready
β’ Excited
β’ Unsure, but willing to try
Anything else you wish to share before our first call?
Short or long answer