Personal Coaching

Personal Information

First Name

Last Name

Email

Mobile

Age

Height

DOB

Place of birth

Occupation

Where do you currently live?

How did you learn about Heidi Jones Health Coaching?

Please list your main health concerns:

What do you want to achieve from coaching?

Do you have any specific goals to accomplish?

The most important thing I should do to improve my health/ lifestyle/ achieve my goal is:

Tell me a little bit more about yourself:

Please provide 3 times for a 20 minute Skype follow-up within the next 7 days:


Personal Coaching (weight loss)

Personal Information

First Name

Last Name

Email

Mobile

Age

Height

DOB

Place of birth

Occupation

Where do you currently live?

How did you learn about Heidi Jones Health Coaching?

Current weight

Weight 6 months ago

Weight 1 year ago

Would you like your weight to be different

Health Information

Please list your main health concerns:

Other concerns or goals:

How is your sleep?

How many hours?

Do you wake up at night? Why?

Any pain, stiffness or swelling?

Constipation/ Diarrhea/ gas?

Allergies or sensitivities? Please explain:

Do you take any supplements or medications? Please list:

What role do sports and exercise play in your life?

Food Information

What is your food like these days?
Breakfast

Lunch

Dinner

Snacks

Liquids

Do you cook? What percentage of your food is home-cooked?

Do you crave sugar, coffee, cigarettes or have any major addictions?

The most important thing I should do to improve my health is:

Please provide 3 times for a 20 minute Skype follow-up within the next 7 days:


Corporate Wellness

Personal Information

First Name

Last Name

Company name:

Company website:

Position in the company:

Email

Phone

Location

How did you learn about Heidi Jones Health Coaching?

Have you reviewed NOW Wellness Coaching Programme brochure?
YesNo

What topic are you interested in learning more (please tick):

BODY
Food workshopFood 4 life seminar

MIND
Being to wellbeing seminarCreating a harmonious life seminar

SPIRIT
Goal setting, motivational health coaching classOff-site Health Coaching Experience

Is this enquiry for:
Staff wellness weekSupport an existing wellness initiativeNew approach to staff wellbeingMiddle managers and leaders1-1 coaching

When would you want to start?

Who would the audience be?

How many would attend?

Please provide 3 times for a 20 minute Skype follow-up within the next 7 days: