Health Coaching Intake Form

You’ve taken the first step to ignite change! So that I can better support you, complete this form no later than 24 hours prior to our first session.

Please complete with as much detail as possible! Although some of these questions may not feel relevant, each helps me understand how to best support you—not just the surface, but the deeper patterns that shape your experience.

Be advised completion may take up to 45 minutes. Thank you!

Name
I would like to receive emails about upcoming events.
MM/DD/YYY
Name and phone
Be descriptive as possible as to what you hope to accomplish or what your "magic wand" life would be like. What do you wish to experience as an outcome of working with me?
Selected Value: 0
How would you rate your motivation to make steps towards achieving this goal? (1 = Not Motivated, 10 = Very Motivated)
Describe how successful these strategies have been.
List as many benefits as possible. What will be different about your behavior? What will be different about your thinking? How will it feel? Who else might be impacted by your success?
List any current health conditions, medications you take regularly, and if you are currently working with a therapist, psychiatrist, or any other practitioner. If relevant to your goals, you are welcome to provide recent bloodwork, weight, or other biometric measurements that may support your progress. This is completely optional and only if you feel it would be helpful to your coaching journey.
Selected Value: 0
How satisfied are you with your sleep? (1 = Not at all, 10 = Completely satisfied)
Selected Value: 0
How satisfied are you with your nutrition? (1 = Not at all, 10 = Completely satisfied)
Selected Value: 0
How satisfied are you with your fitness/movement? (1 = Not at all, 10 = Completely satisfied)
Selected Value: 0
How satisfied are you with your job and career? (1 = Not at all, 10 = Completely satisfied)
Selected Value: 0
How satisfied are you with your emotional and mental health? (1 = Not at all, 10 = Completely satisfied)
Selected Value: 0
How well are you managing your stress right now? (1 = Not at all, 10 = Extremely Well)
Selected Value: 0
How satisfied are you with your social life and sense of connection? (1 = Not at all, 10 = Completely satisfied)
For any of the wellness items above, feel free to provide additional details and context.
Amount/frequency of use and age when you started using
Two parent household? Single parent household? Blended family? Child of divorce? Adopted? Donor conceived?
Briefly describe the most significant relationships in your family of origin (parents, siblings, guardians). You may list names and ages if you wish, but I’m most interested in the emotional nature of these relationships.
Please list partner/spouse. For each, list name, if living/deceased, their age, the nature of the relationship, and the nature in which it ended (if applicable). If not currently in a relationship, describe a significant relationship you've had in the past and the nature in which it ended (divorce with custody battle, amicable break-up, etc).
Name, living/deceased, age, nature of relationships, and any co-parent(s) if applicable. If you do not have children, describe if parenthood or remaining childfree is part of your goals.
Have you experienced any of the following events that may still impact you today? Check all that apply.
If you marked any of the items above, please provide additional details and context.
Describe the role religion, faith, or spirtuality has played in your life. Also mention if you believe in spirits/angels/higher power/past life/afterlife.
Hobbies, passions, activities, creative outlets, social outings...

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Hypnotherapy and Health Coaching with Kat Shinoda
Board Certified Health Coach (NBC-HWC) and Board Certified Hypnotist offering effective methods for weight loss, smoking cessation, alcohol sobriety, and overcoming fears. Proudly serving Montgomery County and surrounding areas, including Collegeville, Skippack, Kimberton, Oaks, King of Prussia, Lansdale, Phoenixville, Pottstown, Reading, Royersford, Paoli, Coatesville, Trappe, Downingtown, Malvern, West Chester, Media, Ambler, Chalfont, Gilbertsville, and Philadelphia.