Wellness Coaching Intake Form 21/22

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Wellness Coaches are here to help you find the motivation and tools that you need to meet your health-related goals. Wellness Coaches are not therapists or psychologists and services may not be right for all students. If you believe that depression, anxiety, or other mental health disorders may be a factor for you, please visit the Skidmore Counseling Center.

The questions on this intake form will provide us with information about your reasons for seeking Wellness Coaching services as well as a preliminary sense of how suitable this service is given your needs. After you submit your form you will be contacted by email within 2 business days regarding next steps.

Please share the name that you prefer to be called:

What is your Skidmore email address?

Please provide your cell phone number:

What are your pronouns?

He/His

She/Her

They/Their

Ze/Zir

Other:

What is your class year?

Senior

Junior

Sophomore

First Year

Clear selection

How did you hear about Wellness Coaching?

Word of mouth

Website

Posters/Restroom Readers

Weeks of Welcome Materials

Referred by another Skidmore office

Other:

Were you referred to Wellness Coaching by Skidmore's Counseling Center?

Yes

Clear selection

Are you currently training to be a Peer Health Educator (PHE)?

Yes

Clear selection

Wellness Coaching is an individualized approach that is most effective at helping students to target specific, concrete goals. With this in mind, please select up to three areas that you hope to focus on with your coach.

Homesickness

Time management

Organization

Stress Management

Procrastination

Relationships issues

Sleep issues

Physical activity

Nutrition

Personal growth

Challenges transitioning to college

Family stressors/obligations

Financial organization/challenges

Self confidence/Self-esteem

Communication skills

Academic performance

Work performance

Work-life balance

Alcohol/other drug related issues

Interpersonal difficulties

Establishing healthy habits

General wellness

Smoking/vaping cessation

Other:

Please share a bit about why you want to focus on the topics that you selected.

Please indicate your general availability below. Your coach will be in touch to offer to time options that fit your preferences.

Monday

Tuesday

Wednesday

Thursday

Friday

Morning (before 10am)

Late morning (10-12)

Early afternoon (12-2)

Afternoon (2-4)

Clear selection

If you have a request for a specific Wellness Coach please specify. Please note that students currently enrolled in the PHE course will not be matched with Jen McDonald.

Kristen Corcoran

Wendy Walker

Kim Golemboski

Jen McDonald

Kara Sysyn

No prefference

Clear selection

Is there anything else that you would like to share with us?

Submit

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