Full Questionnaire Copy
Rooted Resilience
Health Coaching
Complete word-for-word copy for your client intake form — written in your brand voice, ready to paste directly into your form platform.
📋 Full Copy
🎙 Voice Guide
🌱 Thank You Page
Form Introduction — paste at the very top of your form
Welcome to Rooted Resilience Health Coaching
Whether you’re navigating the demands of military life or simply ready to build a healthier, more resilient you — you’re in the right place.
This questionnaire helps me understand where you’re starting from and where you want to go, so we can build a plan that actually fits your life — your schedule, your season, your goals.
There are no right or wrong answers here. Just be honest, take your time, and know that everything you share is completely confidential. This is your space.
⏱ Takes about 8–12 minutes · 6 short sections · Your answers are saved automatically
Form Progress Bar — show these 6 steps at the top of each page
01
About You
›
02
Your Goals
›
03
Your Health
›
04
Your Mindset
›
05
How We Work
›
06
Final Notes
Section 01
About You
Let’s start with the basics
“Before we dive in, I’d love to know a little about you. This section is quick — just the essentials so I know how to reach you and how you found your way here.”
TypeShort text Required
QuestionWhat is your full name?
TypeShort text Optional
QuestionWhat would you like me to call you?
Hint textNickname, first name, callsign — whatever feels right to you.
TypeEmail + Phone fields Required
QuestionWhat’s the best email address and phone number to reach you?
Hint textYour information is kept private and will only be used to connect with you about your coaching experience.
TypeDropdown Optional
QuestionHow did you hear about Rooted Resilience?
OptionsA friend or family member referred me / Instagram / Facebook / Google search / Military community or resource / Other
Section 02
Your Goals & What Drives You
Let’s get clear on where you want to go
“This is where we start building your north star. The clearer you can be here, the more focused and effective our work together will be. Don’t hold back.”
TypeLong text Required
QuestionWhat is the #1 health or wellness goal you want to achieve in the next 3–6 months?
Hint textThe more specific, the better. “Lose weight” is a start — but “have consistent energy to keep up with my kids after a long duty day” tells me so much more.
TypeLong text Required
QuestionWhy does this goal matter to you right now? What’s your deeper “why”?
Hint textSometimes it’s a PCS that reset your routine. Sometimes it’s a deployment that changed you. Sometimes it’s just knowing you deserve to feel better. Whatever it is — I’d love to hear it.
TypeMulti-select checkboxes Required
QuestionWhich areas of wellness are you most ready to focus on? (Select all that apply)
OptionsNutrition & my relationship with food / Energy & fighting fatigue / Sleep quality / Stress & nervous system support / Weight & body composition / Movement & fitness / Mindset & building better habits / Hormones & gut health
TypeYes / No with conditional follow-up Required
QuestionHave you worked with a health coach or wellness professional before?
If Yes →Tell me about it. What worked well? What didn’t? What do you wish had been different?
If No →No worries at all — that’s exactly what I’m here for. We’ll figure it out together.
Section 03
Your Current Health & Lifestyle
No judgment — just a starting point
“Military life throws a lot at your body — irregular schedules, high-stress environments, frequent moves. I want to understand your real daily life, not the ideal version. Be honest. That’s how we build something that actually sticks.”
TypeLong text Required
QuestionHow would you describe your current eating habits on a typical week?
Hint textThink about what a normal day looks like — not your best day or worst day. Do you skip meals? Rely on the DFAC or fast food? Stress eat? Eat well but then fall off on the weekends? All of it is useful to know.
TypeNumber scale 0–7 Required
QuestionOn average, how many nights a week do you get 7 or more hours of sleep?
Hint textWe know military schedules don’t always cooperate — just give me your honest average.
TypeSingle select Required
QuestionHow would you describe your current activity level?
OptionsMostly sedentary — movement isn’t really part of my routine right now / Lightly active — I move a little, maybe 1–2x a week / Moderately active — I’m consistent, 3–4x a week / Very active — I train regularly, 5+ days a week
TypeSlider 1–10 Required
QuestionOn a scale of 1–10, how would you rate your current stress levels?
Hint text1 = feeling calm and grounded · 10 = running on fumes and barely keeping it together
TypeLong text Optional
QuestionAre there any health conditions, medications, injuries, or dietary needs I should know about before we start?
Hint textThis might include things like thyroid issues, chronic pain, food allergies, service-connected injuries, or anything else that shapes how you feel day-to-day. Your response is completely confidential and helps me create a plan that’s safe and right for you.
Section 04
Mindset, Challenges & Your Vision
The inner work that makes the outer work possible
“Resilience isn’t just physical — it’s built from the inside out. These questions help me understand your relationship with change, your history, and the vision that’s going to pull you forward when things get hard.”
TypeLong text Required
QuestionWhat has been the biggest obstacle that’s held you back from reaching your health goals in the past?
Hint textBe real with me. Is it time? Energy? Motivation? A PCS that derailed your routine? Feeling like you always put everyone else first? There’s no wrong answer — this is where we start breaking through.
TypeSlider 1–10 Required
QuestionOn a scale of 1–10, how ready and committed are you to making real changes right now?
Hint text1 = just exploring, not quite ready · 10 = I’m all in, let’s go · Wherever you are is okay — honesty helps me meet you where you are.
TypeLong text Required
QuestionPicture yourself 6 months from now, feeling your absolute best. What does your life look like?
Hint textPaint the picture. How do you feel when you wake up? What can you do that you can’t do now? How do you show up for your family, your unit, or yourself? This is your vision — make it vivid.
TypeSingle select + optional comment Optional
QuestionDo you have people in your corner who will support you on this journey?
OptionsYes — my family and/or community are very supportive / Somewhat — some people get it, some don’t / Not really — I’m mostly doing this on my own / I prefer to keep this private for now
Hint textThere’s no right answer. Whether you have a squad behind you or you’re flying solo, we’ll make it work.
Section 05
How We’ll Work Together
Let’s make this coaching relationship work for your life
“Everyone thrives differently. These questions help me tailor my coaching style and communication to fit you — not the other way around.”
TypeMulti-select checkboxes Required
QuestionWhat kind of coaching energy resonates most with you? (Select all that apply)
OptionsStrong accountability — check in on me and hold me to it / Motivational — hype me up when I need it / Educational — give me the “why” behind what we’re doing / Compassionate — meet me with grace, especially on hard weeks / Flexible — I need a plan that bends, not breaks
TypeMulti-select checkboxes Required
QuestionHow do you prefer to stay connected between sessions?
OptionsEmail / Text or WhatsApp / App-based check-ins / I’d rather keep communication to our sessions
Hint textI’ll follow your lead on this — you set the pace.
TypeSingle select Required
QuestionRealistically — given your schedule, your family, your duties — how many hours per week can you commit to your wellness goals outside of our sessions?
OptionsLess than 2 hours — my time is tight, keep it simple / 2–4 hours — I have some room to work with / 4–6 hours — I’m ready to put in real effort / 6+ hours — I’m treating this like a mission
Hint textHonest answers here lead to a plan that’s actually achievable. Progress beats perfection every time.
Section 06
Final Thoughts & Agreement
Almost there — just a couple more things
“You’ve made it to the end — thank you for taking this seriously. Last thing: is there anything I should know that we haven’t covered yet?”
TypeLong text Optional
QuestionIs there anything else you’d like me to know before we start working together?
Hint textThis is your space. Maybe there’s a unique challenge that comes with your duty station, your family situation, or your season of life. Maybe there’s something you’ve been carrying that feels relevant. Whatever it is, I’m listening.
TypeCheckbox consent Required
QuestionI understand that my responses are confidential and I agree to the Rooted Resilience Privacy Policy.
Hint text← Link “Privacy Policy” to your published privacy policy URL before going live
ButtonSubmit & Take the First Step →
Thank You Page — shown immediately after form submission
You just took a powerful first step. 🌱
Thank you for trusting me with your story. Taking the time to fill this out — honestly and completely — tells me you’re serious about this, and I’m already excited to work with you.
I’ll personally review your answers and reach out within 48 hours to schedule your first session. Keep an eye on your inbox — and check your spam folder just in case.
In the meantime, know this: wherever you’re starting from, there’s a path forward. We’ll build it together.
— Rooted Resilience Health Coaching