Wellness Intake Form: Template, Example and Tips
A wellness intake form is the questionnaire a new client completes before your first session so you know their goals, current habits, health context, readiness for change and any reason they should see a doctor before you start. The free template below gives wellness coaches eight sections you can copy today: contact and consent, goals, a lifestyle snapshot across sleep, stress, movement, food and energy, a short health screen with red flags, their care team, readiness and support, logistics, and a signed acknowledgement of what coaching is and is not.
Where you run it matters as much as the wording. In Coachful, the intake questions sit on your booking page, the coaching agreement is signed before the first call, and every answer is stored on the client record next to their goals, habits, check-ins and invoices. We make Coachful, so read the comparison later in this guide with that in mind; the template itself works on paper, in a Google Form or in any tool you already use.
What does a complete wellness intake form contain?
A complete form covers who the client is, what they want, how they live now, whether anything needs medical clearance, and what they have agreed to. Use this checklist to audit the form you have, or to check the template below against your own practice.
| Section | What it captures | Must have? |
|---|---|---|
| 1. Contact, emergency contact and consent | Name, pronouns, time zone, preferred contact channel, emergency contact, consent to store answers | Yes |
| 2. Goals and motivation | The outcome in their words, why now, what success looks like in 12 weeks | Yes |
| 3. Lifestyle snapshot | Sleep, stress, movement, eating pattern, hydration, caffeine, alcohol, screen time, energy across the day | Yes |
| 4. Health screen and red flags | Yes or no questions that trigger a referral or doctor's clearance before you continue | Yes |
| 5. Care team | Doctor, therapist, dietitian or other practitioners, and permission to coordinate | Recommended |
| 6. Readiness, past attempts and support | Confidence scale, what they have tried, who supports or undermines change | Yes |
| 7. Logistics and preferences | Session times, check-in frequency, how they like feedback, accessibility needs | Recommended |
| 8. Scope acknowledgement and signature | Coaching is not medical care, confidentiality limits, data use, signature and date | Yes |
If your current form misses sections 4 or 8, fix those first. They are the two that protect the client and you. For a broader view of how intake fits a health practice, the health coaching intake form template goes deeper on clinical-adjacent questions, and 15 coaching intake form questions covers phrasing for any niche.
The free wellness intake form template
Copy everything in this section into your form tool and replace each [bracketed] item with your own details. Questions are written to be answered in two to five minutes per section, so the whole form takes most clients about 15 to 20 minutes.
[Your practice name] Wellness Coaching Intake Form
Thank you for booking with [your name]. Your answers help me plan our first session around what matters to you. Skip any question you would rather discuss in person. Everything you share stays between us, except where the law or your safety requires otherwise (see Section 8).
Section 1: About you
- Full name, and the name you would like me to use:
- Pronouns (optional):
- Email and mobile number:
- City and time zone:
- Date of birth (I work with adults aged [18 or your minimum] and over):
- Best way to reach you between sessions: [in-app message / email / text]
- Emergency contact name, relationship and phone number:
- How did you hear about [your practice name]?
Section 2: Your goals
- In one or two sentences, what do you want to feel or be doing differently by the end of our [12-week] program?
- Why is now the right time to work on this?
- Rank these areas from most to least important right now: sleep, stress, energy, movement, eating habits, weight, work-life balance, relationships, purpose, other: [ ]
- Picture a normal Tuesday three months from now, going well. What is different from today?
- How will you know coaching has been worth it? Name one sign you could notice yourself.
Section 3: Your current routine
- Sleep: What time do you usually go to bed and wake up on workdays? On days off? How rested do you feel on waking, from 1 (exhausted) to 10 (fully rested)?
- Stress: On a scale of 1 to 10, how stressed have you felt over the last two weeks? What are the two biggest sources?
- Recovery: What do you currently do to unwind (walks, reading, breathwork, prayer, scrolling, a drink, nothing)?
- Movement: On how many days a week do you move on purpose for 20 minutes or more? What kind of movement do you enjoy, or used to enjoy?
- Sitting: Roughly how many hours a day do you sit for work, travel and screens?
- Eating pattern: Describe a typical day of meals and snacks. Do you skip meals, eat late, or eat on the go?
- Hydration and stimulants: How much water, caffeine and alcohol do you have on a typical day or week?
- Energy: When during the day do you feel most and least energetic?
- Tracking: Do you already track anything (steps, sleep, meals, cycle, mood)? Which app or device, and do you want to keep using it?
Section 4: Health screen
Wellness coaching supports healthy habits; it does not diagnose or treat any condition. If you answer yes to any question below, I will ask you to speak with your doctor and share their go-ahead before we start movement or eating changes. A yes does not mean we cannot work together.
- Has a doctor ever told you that you have a heart condition or high blood pressure, or that you should only do physical activity they recommend? [yes / no]
- Do you feel pain or pressure in your chest, or lose your balance or consciousness, during or after physical activity? [yes / no]
- Are you currently pregnant, or have you given birth in the last 6 months? [yes / no]
- Are you being treated for diabetes, a thyroid condition, kidney disease, cancer or another ongoing condition? [yes / no; details optional]
- Have you had surgery, a significant injury or a hospital stay in the last 12 months? [yes / no]
- Do you take any prescribed medication that a change in eating, fasting, alcohol or exercise could affect? [yes / no; you do not need to list it here]
- Have you had, or are you being treated for, an eating disorder or disordered eating? [yes / no / prefer to discuss]
- Have you lost weight without trying in the last 6 months? [yes / no]
- In the last two weeks, have you often felt down, hopeless or had little interest in things you usually enjoy? [yes / no / prefer to discuss]
- Are you currently having thoughts of harming yourself? [yes / no]. If yes, please contact [your local emergency number or crisis line] now; I will also follow up with you directly.
Section 5: Your care team
- Do you have a GP, family doctor or primary care provider? [yes / no]
- Are you working with a therapist, dietitian, physiotherapist, naturopath or other practitioner at the moment? Who, and for what?
- May I contact them, with your written permission, if it would help our work? [yes / no / ask me each time]
Section 6: Readiness and support
- How ready do you feel to make changes, from 1 (not yet) to 10 (ready today)?
- How confident are you that you can keep a new habit for 4 weeks, from 1 to 10?
- What have you tried before for this goal? What worked, even briefly, and what made it stop?
- Who in your life will support these changes? Who might make them harder?
- What is the biggest obstacle you expect in the next month (travel, shift work, caring for others, money, motivation)?
- How many hours a week can you realistically give to this, outside our sessions?
Section 7: How you like to work
- Preferred session days and times: [morning / midday / evening; weekdays / weekends]
- How often would you like a check-in between sessions? [daily / a few times a week / weekly]
- When you slip, what kind of message helps most? [a gentle nudge / a direct question / space until our next session]
- Do you have any accessibility needs, dietary, cultural or religious practices I should know about?
- Anything else you want me to know before we meet?
Section 8: Agreement
Please read and tick each statement.
- [ ] I understand that [your name] is a wellness coach and not a doctor, therapist or registered dietitian, and that coaching does not replace medical, psychological or nutritional care.
- [ ] I will tell my coach about any change in my health or medication, and I will speak with my doctor before starting new exercise or eating changes if I answered yes in Section 4.
- [ ] I understand my coach will keep my information confidential, except where there is a risk of serious harm to me or others, or where the law requires disclosure.
- [ ] I agree that my answers are stored in [your platform] for the purpose of coaching me, and I can ask for a copy or for deletion at [your contact email].
- [ ] I have read the coaching agreement covering fees, cancellations and session policy, which I will sign separately.
Signature: [ ] Date: [ ]
Why does each section matter, and what should you watch for?
Every section earns its place by changing what you do in session one. This table explains the purpose of each part of the template and the answers that should make you pause.
| Section | Why it matters | What to watch for |
|---|---|---|
| About you | Gets time zones and contact channels right from the start, and gives you an emergency contact for live or in-person work | A client under your minimum age; a missing emergency contact for anyone doing physical activity with you |
| Goals | Turns a vague "feel better" into a sign you can both observe, which becomes your first program goal | Goals that are really treatment requests ("fix my thyroid", "get off my medication") |
| Current routine | Shows where the easiest first habit is; sleep and stress answers often explain the energy and eating answers | Very short sleep with high stress and heavy caffeine or alcohol: start with recovery, not a training plan |
| Health screen | Decides whether you need a doctor's clearance before movement or eating changes | Any yes on questions 1 to 8; any yes on 9 or 10 needs a same-day response and a referral |
| Care team | Keeps you in your lane and lets advice line up with what their clinicians say | A client who wants you to overrule a clinician's plan |
| Readiness and support | Low readiness or confidence tells you to start smaller, or to spend session one on motivation | Readiness of 3 or less, or a support network that is actively hostile to change |
| How you like to work | Sets check-in frequency and tone so your between-session messages land | Requests for daily contact your package does not include: address it in the agreement |
| Agreement | Records that the client understands what coaching is, how their data is used and when confidentiality ends | Unticked boxes; never start a program with the scope statement unacknowledged |
If you run many intakes a week, scoring readiness and red-flag answers automatically saves reading time. How to automate coaching intake form scoring shows one way to set that up.
What must wellness coaches add for scope, safety and data?
Wellness coaches need four additions beyond good questions: a clear scope statement, a referral rule for red flags, care with sensitive health data, and a check against local law. The template includes a starting point for each; here is how to tailor them.
Scope of practice
Coaching is not treatment. You support behaviour change, habits and accountability; you do not diagnose, prescribe, or design meal plans for medical conditions unless you hold a licence that allows it. The National Board for Health and Wellness Coaching (NBHWC) publishes a scope of practice for certified coaches, and it is a sensible reference even if you hold a different credential. Put your own credential in Section 8 in plain words, for example "certified wellness coach, not a registered dietitian".
Red flags and referral
Section 4 borrows its logic from physical activity readiness screening. The best known screen is the PAR-Q+ (Physical Activity Readiness Questionnaire for Everyone); you can read about its history on Wikipedia. Do not paste the official PAR-Q+ into your form; it is a copyrighted document. Paraphrase, as the template does, and if you coach exercise directly, ask clients to complete the official version from its publisher.
Decide your referral rule before a client answers. A workable one:
- Any yes on questions 1 to 8: pause movement and eating changes, ask for written clearance from their doctor, and keep coaching on goals, sleep routines and stress in the meantime if their doctor agrees.
- Question 7 (eating disorder): refer to a clinician who specialises in eating disorders; do not set calorie, weight or fasting goals.
- Question 9 (low mood): talk about it in session one and suggest a GP or therapist; coaching can continue alongside care.
- Question 10 (self-harm): respond the same day. In the US, the 988 Suicide and Crisis Lifeline is available by call or text; elsewhere, list your country's crisis line in the form itself.
Sensitive health data
Health answers are sensitive, even when you are not a healthcare provider. In the US, HIPAA applies to covered entities such as health plans and providers who bill electronically; the HHS covered entities guidance explains who that is. Most independent wellness coaches are not covered entities, but if you work inside a clinic or bill insurance you probably are, and then your records belong in a clinical system with a business associate agreement. Coachful is not HIPAA-certified and does not sign a BAA, so keep clinical records out of it.
In the UK and EU, health data is "special category data" under the GDPR (Article 9). The UK regulator's guide to special category data explains that you need explicit consent or another condition to process it. That is why Section 8 asks for consent to store answers, and why the health screen asks yes or no rather than inviting a full medical history. Collect only what changes your coaching.
Local law
Rules on minimum age, record retention, consent wording and who may give nutrition advice vary by state and country. Some US states restrict individualised nutrition advice to licensed professionals. Check yours, and see the closing note on when to bring in a lawyer.
What does a completed wellness intake form look like?
This is an example for a fictional client, written to show the level of detail a useful answer has. Nothing here is a real person.
Example only: "Dana R.", fictional client
Section 1: Dana R., they/them, Leeds (GMT). Prefers in-app messages. Emergency contact: Sam R., partner. Found the practice through a workplace wellbeing talk.
Section 2: "I want to stop crashing at 3pm and stop relying on wine to switch off." Now, because a promotion doubled their hours. Ranking: energy, stress, sleep, movement, eating habits. Good Tuesday in three months: "Lunch away from my desk, a walk after work, in bed by 11 without my phone." Sign of success: "Fewer than two glasses of wine on weeknights."
Section 3: Bed 12:30am, up 6:45am on workdays; rested 4 of 10. Stress 8 of 10, from workload and caring for a parent. Unwinds with TV and wine. Moves on purpose one day a week. Sits about 10 hours a day. Skips breakfast, eats lunch at the desk, big dinner at 9pm. Four coffees a day; 8 to 10 units of alcohol a week. Energy peaks at 10am, drops at 3pm. Tracks steps on a phone.
Section 4: All no, except question 9: "Prefer to discuss."
Section 5: Has a GP; no other practitioners. Permission to contact: ask each time.
Section 6: Readiness 7 of 10; confidence 5 of 10. Tried a running app twice, stopped after two weeks each time during busy months. Partner supportive; team drinks culture makes alcohol harder. Expects quarter-end deadlines to be the obstacle. Can give 3 hours a week.
Section 7: Tuesday evenings. Check-ins a few times a week. When they slip: "A direct question, not a pep talk." No dietary or accessibility needs.
Section 8: All boxes ticked, signed and dated.
Reading this, a coach would open session one by asking about the "prefer to discuss" answer on mood, privately and without pressure, and suggest a GP conversation if low mood has lasted. The first habit would sit around sleep and the evening wind-down rather than exercise, because short sleep, high stress and alcohol are linked in Dana's answers and the running app failed twice. A 15-minute walk after work could come in week three, once confidence rises above 5.
How do you run a wellness intake form in Coachful?
In Coachful, the intake form is one step in a client journey that runs from booking to program delivery under one login. Coachful is a coaching platform for coaches who deliver programs, not just sessions: one subscription covers booking, payments, contracts, programs with habits and check-ins, courses, a community, a website with funnels and email, and an AI assistant, with one branded app for your clients. It suits solo wellness coaches and small teams replacing four to six separate tools. It is not a clinical system: it is not HIPAA-certified, it does not handle insurance billing, and it does not sync with Garmin, Fitbit, Whoop or Oura. To start, take a free trial, or ask the team to build your setup for you at no charge.
Here is how the template maps to the screens a coach and client actually use.
Step 1: Put the intake questions on your booking page
Add Sections 1 to 7 as intake questions on your discovery or first-session booking type. The client answers while booking, so you read their goals and red flags before you meet. Booking pages handle availability rules, buffers, minimum notice and time-zone detection, and sync with Google, Apple/iCloud or Outlook calendars. Each booking appears on the Intakes page, which tracks upcoming and converted intakes. This short walkthrough shows the intakes view:
Step 2: Send the agreement before the first call
Section 8 works best as part of your coaching agreement. Coachful sends agreements for e-signature before the first call and stores the signed copy on the client record. Add the scope, confidentiality and data statements from the template to your fees and cancellation terms. The coaching contracts page explains the signing flow.
Step 3: Read the answers on the client record
Intake answers sit on the client record with goals, check-ins, habits, notes, tags, payments and sessions. Tag anyone with a health-screen yes (for example "clearance needed") so the status is visible before every session. Michelle, the built-in AI assistant, can brief you on a client before the call using that live data. Each client also shows a status of thriving, active, quiet or at risk once the program is running.
Step 4: Turn the answers into check-ins and habits
Section 3 tells you which check-in to switch on. A client like Dana, with a sleep and stress goal, could get an evening check-in on wind-down and a morning check-in on how rested they feel, using the same 1 to 10 scales from the intake so you can compare. Habits with streaks track the first small change.
Step 5: Enrol them in a program
Multi-week programs carry weekly goals, daily tasks, habits and check-ins, and group programs create a cohort group automatically on enrolment. Coachful includes more than 40 program templates you can adapt to a 12-week wellness reset.
What the client sees
Your client uses your branding inside the Coachful app. Their coaching hub shows the next session, any pre-session task (such as finishing the intake), their programs, progress and a Documents tab for the signed agreement.
Step 6: Take payment and issue invoices
Payments run through your own Stripe Connect or Razorpay account, with one-time payments, subscriptions and payment plans. Every transaction gets an invoice, and you can raise manual ones. Coachful charges a 0% platform fee; only processing fees apply. Current plans: (Lite: $29/month for up to 5 clients; Solo: $49/month for up to 20 clients; Pro: $99/month with unlimited clients; Studio: $199/month with unlimited clients).
Why Coachful stands out: a free white-glove service. From Create, choose "We'll build it for you" and describe what you need: your intake form, a booking funnel, a 12-week program or a full website. You can attach up to 8 reference links and up to 10 files, such as this template with your edits and your logo. The Coachful team builds it inside your own account, usually within about 24 hours, and leaves gaps for you rather than inventing credentials or prices. A menopause and midlife health coach starting from nothing, for example, got a five-page site in sage and cream with every button leading to a free 20-minute consultation. Read more about the white-glove build service.
What are the ways to send and store a wellness intake form?
You can send this form as a file, an online form, through an e-signature tool or inside a practice platform. The difference is where the answers end up: in an inbox, a spreadsheet, or on the client record you use every week. Vendor prices below are as listed in October 2026.
| Option | How the client completes it | Where answers are stored | Signing | Cost |
|---|---|---|---|---|
| Coachful | Intake questions on the booking page, inside your branded app | On the client record with goals, habits, check-ins, sessions and payments | Coaching agreement with e-signature before the first call | Lite: $29/month for up to 5 clients |
| PDF or Word file | Downloads, fills in, emails back or brings on paper | Your inbox or a folder; retyped by you | Wet or typed signature | No software cost |
| Google Forms or Docs | Online form link | A spreadsheet or document in your Google account | None built in; tick-box consent only | Included with a Google account |
| An e-signature tool | Signs a document sent by email | In the e-signature account, separate from your coaching records | Yes | Varies by tool and plan |
| Practice Better | Through its client portal | In the client's practice record alongside charting | Check its current documentation | Sprout $0/mo (3 clients); Starter $35/mo; Professional $69/mo |
| Dubsado | Lead-capture or questionnaire forms | On the client's project in the CRM | Contracts | Starter $35/mo; Premier $55/mo |
| HoneyBook | Lead forms and questionnaires | On the client's project in the CRM | Proposals and contracts | Starter $29/mo billed annually; Essentials $59/mo |
A PDF is fine for your first three clients. Once you are retyping answers into a spreadsheet and chasing signatures by email, the time cost shows. Google Forms collects answers well but leaves signing, booking and follow-up to other tools. If you want a wider look at form tools for this audience, see intake form software for holistic health coaches or the roundup of software for wellness coaches.
Other practice tools wellness coaches use
Practice Better is practice management for wellness and nutrition practitioners, with scheduling, telehealth, charting, billing, programs and a client portal; it lists a free Sprout plan for three clients and a 14-day trial on most paid plans. Dubsado and HoneyBook are client-workflow CRMs for service businesses with forms, contracts and invoices, but no programs, habits, check-ins or community for coaching delivery; Dubsado lists a 21-day trial and HoneyBook a 30-day trial. Quenza focuses on activities, worksheets and a client app, and lists no client payment processing today.
What are the most common wellness intake form mistakes?
Most problems come from asking too much, asking the wrong things, or doing nothing with the answers.
- Copying a medical history form. A full list of diagnoses, medications and test results is clinical data you probably cannot use and should not store. Ask yes or no screening questions and refer.
- No referral rule. A health screen without a decided response is worse than none: you have seen the red flag and done nothing. Write your rule before you send the form.
- Burying the scope statement. If "coaching is not medical care" appears only in the small print, clients will not read it. Make it a ticked statement in the signed section.
- Asking for weight or body measurements by default. For many wellness clients, and for anyone with a history of disordered eating, this can harm trust. Ask only if their goal needs it, and let them skip.
- Too long for the first contact. If you put all eight sections on a free discovery call, completion drops. Use Sections 1, 2 and 4 for discovery, and send the full form after they buy.
- Answers stored in three places. Form in Google, signature in email, notes in a notebook. When a client mentions a new medication in month two, you need one record to update.
- Never revisiting it. Readiness, stress and sleep change. Re-ask the Section 3 and 6 scales at week 6 and week 12 to show progress in the client's own numbers.
- Generic questions. "What are your goals?" gets "be healthier". The template's "normal Tuesday" question gets something you can coach.
The client onboarding form guide covers what to send after intake, and the coaching forms and questionnaires page shows the other forms you can run alongside this one.
Is this template legal or medical advice?
No. This template and guide are general information for wellness coaches, not legal, medical or financial advice. Laws on health data, consent, minors and nutrition advice vary by state and country. Have a local lawyer review your agreement and consent wording before you use them, especially if you coach minors, work across borders, or collect detailed health information. Ask a doctor or another licensed clinician to review your health screen and referral rule if you coach movement or eating changes, or if you work with clients who have ongoing conditions.
Frequently asked questions
What should a wellness intake form include?
At minimum: contact and emergency details, goals in the client's words, a lifestyle snapshot of sleep, stress, movement and eating, a yes or no health screen with red flags, readiness for change, and a signed statement that coaching is not medical care. Care team details and session preferences are worth adding for most practices.
Is this wellness intake form template free to use?
Yes. Copy it, edit it and use it in your practice. Replace every bracketed item with your own details and have a local lawyer check the agreement section before you rely on it.
How long should a wellness intake form be?
Aim for 15 to 20 minutes for the full form. For a free discovery call, send a shorter version with contact details, goals and the health screen, then send the rest after the client signs up.
Do wellness coaches need clients to see a doctor first?
Not always. Ask for a doctor's clearance when a client answers yes to a screening question about heart conditions, chest pain, pregnancy, recent surgery, ongoing treatment or medication that exercise or eating changes could affect. Refer immediately for self-harm risk.
Can I store wellness intake forms in Coachful?
Yes. Intake answers are stored on the client record alongside goals, check-ins, habits, notes and sessions, and you can export all client data as a ZIP. Coachful is not HIPAA-certified, so clinical records and insurance billing belong in a clinical system.
Is my wellness coaching practice covered by HIPAA?
Most independent wellness coaches who are paid directly by clients are not HIPAA covered entities. If you work for a clinic, a health plan or bill insurance electronically, you may be. Check the HHS covered entities guidance and ask an attorney if you are unsure.
What is the difference between an intake form and a coaching agreement?
The intake form gathers information about the client. The coaching agreement sets the terms: fees, cancellations, scope, confidentiality and data use, signed by both of you. Many coaches put the scope acknowledgement in both.
How is a wellness intake form different from a nutrition or personal training form?
A wellness form looks across sleep, stress, movement, eating and purpose rather than going deep on one area. If you coach food or training in detail, see the nutrition intake form or the personal training client intake form.
What is Coachful's free white-glove build service?
It is a done-for-you build included on every plan. You describe what you want, such as an intake form, booking funnel, program or website, attach references, and the Coachful team builds it inside your account, usually within about 24 hours. It does not include recording videos, logo design or ongoing marketing.
Can I generate a custom wellness intake form instead of editing this one?
Yes. The intake form generator builds a form from your niche and session type, which you can then refine with the red-flag and scope sections from this template.
