New Client Start Here

You said yes. Now let's make sure we're building the right thing. Tell me what you're working on, what matters most, and anything I should know before we get rolling.

CLIENT INFORMATION

First name

Last name

Date of birth

Month

Day

Year

Phone

Street address

City

State

ZIP code

Marital status

Occupation

Number of children

Children's ages

YOUR GOALS AND CURRENT CONCERNS

What brings you here, and what do you hope to change?

Other concern or details

CURRENT CARE AND HEALTH HISTORY

What have you already done or been advised to do?

Current medications, including dose if known

Vitamins, herbs, and supplements

Allergies or sensitivities

Current physicians or other care providers

Surgeries, hospitalizations, or significant injuries, with approximate dates

Family history of illness or disease

Current diagnoses or ongoing medical conditions

LIFESTYLE

Current level of exercise

Average sleep and sleep quality

Do you change your diet often? If yes, what prompts the change?

Anything else that should be addressed before we work together?

WELLNESS COACHING ACKNOWLEDGMENT

I understand that services provided by Brooke Chapel are educational and supportive wellness-coaching services intended to help me explore habits, nutrition, lifestyle choices, stress management, and personal wellness goals.

Wellness coaching is not medical care and is not intended to diagnose, treat, cure, mitigate, or prevent any disease, injury, or medical condition. Brooke Chapel is not acting as my physician or other licensed medical provider. Coaching does not replace medical examination, diagnosis, treatment, counseling, or emergency care.

I will seek appropriate care from a qualified medical professional for medical symptoms or concerns. I will not start, stop, or change prescription medication or medical treatment without consulting the prescribing or treating medical professional.

Nutrition, supplement, movement, and lifestyle information is general education. Participation is voluntary, and no particular outcome has been promised or guaranteed.

If I have an emergency, severe or rapidly worsening symptoms, or thoughts of harming myself or someone else, I will contact 911 or another appropriate emergency resource.

I have read and understand the wellness coaching acknowledgment above, have had an opportunity to ask questions, and voluntarily consent to participate.

Type your full legal name as your signature

Date signed

Month

Day

Year