Client refer form - Healthy Living Coach™

Healthy Living Coach™

Brooklyn, NY

You Have Been Referred To A Certified Health Coach

Hi, I’m Coach Charity.

Your health care provider ( Doctor, Nurse Practitioner) has referred you to Healthy Living Coach™ ONLINE HEALTH COACHING.
Coaching is provided for healthy meals and regular exercise.

The short term goal is to lose a minimum of 5% of your current weight. The intermediate goal is to lose 10% of the weight that you are today. The long term goal is to maintain the weight loss and continue in a pattern of healthy meal choices and regular exercise.

Coaching ONLINE means communication between you and your coach will include using text messages, emails and group video conferences such as zoom. Your coach will assign you homework exercise activity.

1. Are you interested in having a Health Coach?

Yes I would like more information before I decide No

If you answered yes, or, you would like more information before you decide, please provide best contact info and best time to contact you below.

2. First and Last Name

3. Date of Birth MM/DD/YYYY

4. Email

5. How do you want to be contacted for phone calls and Texts?

WhatsApp Call Home Phone, Land Line Cell Phone

6. What are the best times of day to receive a call from Healthy Living Coach to provide you with information about this program and answer your questions about this ONLINE health coaching program ?

Questions 7 to 15 require only a True or False response.
You want your answers to reflect where you are "now", not how you would like to be in the future.

7. I have thought a lot about my eating habits and physical activities to pinpoint what I need to change.

True False

8. I have accepted the idea that I need to make permanent, not temporary, changes in my eating and activities to be successful.

True False

9. I will only feel successful if I lose a lot of weight.

True False

10. I accept the idea that it's best if I lose weight slowly.

True False

11. I'm thinking of losing weight now because I really want to, not because someone else thinks I should.

True False

12. I think losing weight will solve other problems in my life.

True False

13. I am willing and able to increase my regular physical activity.

True False

14. I can lose weight successfully if I have no "slip ups."

True False

15. I am ready to commit some time and effort each week to organizing and planning my food and physical activity programs.

True False

16. Once I lose some weight, I usually "lose "the motivation to keep going until I reach my goal.

True False

17. I want to start a weight loss program, even though my life is unusually stressful right now.

True False

18. A. What is your goal weight, goal clothing sizes? B. Have you achieved these goals in the past? if yes, when were you at a preferred size or weight ?

Use this guide to measure your waist.

19. What is your waist measurement in inches?

20. List all of the exercises that you do not like, are not your favorite, that you would avoid doing.

21. List all of the exercises and exercise activities that you enjoy and would prefer to do.

Planning for next week, based on your work and life schedule, please answer question below

24. If you selected "Other" in the question above please explain here

25. Select all that you have used for video chats or meetings?

I have used face time on my cell phone I have used zoom I have used Google meet I have used Facebook video chat or Facebook Live I have used Go To Meeting I have used Skype I have used other platforms for video meetings

26. Which of these do you use most of the time to access the internet?

Laptop Tablet Android Iphone

27. Enter any immediate question and comments here.

Sign here

I agree to use electronic records and signatures.

The next step: If you indicated that you are interested in Health Coaching, you will be guided on the next step. Expect communication via email, text and phone. If you have a question about something unclear on this form, send a text or WhatsApp to 929-213-7289. or email healthylivingcoachusa@gmail.com.

Healthy Living Coach™

You Have Been Referred To A Certified Health Coach

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