Remote Wellness Coach Session Scheduling Spring 2020

Wellness Coaching Intake Form

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.

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* 1. What is your name?

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* 2. What is your Skidmore email address?

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* 3. What are your pronouns?

he/his

she/her

they/their

ze/zir

Other (please specify)

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* 4. What is your class year?

Senior

Junior

Sophomore

First Year

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* 5. How did you hear about Wellness Coaching?

Word of mouth

Website

Posters/Fliers/Restroom Readers

Weeks of Welcome materials

Other

Referred by another Skidmore office (please specify):

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* 6. Were you referred to Wellness Coaching by the Skidmore Counseling Center?

Yes

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* 7. Are you a Peer Health Educator (PHE)/Currently training to become a PHE?

Yes

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* 8. Wellness Coaching is an individualized approach that is most effective at helping students to target specific and 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

relationship issues

sleep issues

physical activity

nutrition

personal growth

challenges transitioning to college

family stressors/obligations

financial organization/issues

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 specify)

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* 9. Please tell us a bit about why you want to focus on the topics that you selected.

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* 10. For the remainder of the semester we will be offering Wellness Coaching remotely using Zoom. Please indicate your general availability below. Your coach will be in touch to offer you time options that fit your preferences.

	Monday	Tuesday	Wednesday	Thursday	Friday	Sunday
Morning (before 10am)	Morning (before 10am) Monday	Morning (before 10am) Tuesday	Morning (before 10am) Wednesday	Morning (before 10am) Thursday	Morning (before 10am) Friday	Morning (before 10am) Sunday
Late Morning (10-12)	Late Morning (10-12) Monday	Late Morning (10-12) Tuesday	Late Morning (10-12) Wednesday	Late Morning (10-12) Thursday	Late Morning (10-12) Friday	Late Morning (10-12) Sunday
Early afternoon (12-2pm)	Early afternoon (12-2pm) Monday	Early afternoon (12-2pm) Tuesday	Early afternoon (12-2pm) Wednesday	Early afternoon (12-2pm) Thursday	Early afternoon (12-2pm) Friday	Early afternoon (12-2pm) Sunday
Afternoon (2pm - 5pm)	Afternoon (2pm - 5pm) Monday	Afternoon (2pm - 5pm) Tuesday	Afternoon (2pm - 5pm) Wednesday	Afternoon (2pm - 5pm) Thursday	Afternoon (2pm - 5pm) Friday	Afternoon (2pm - 5pm) Sunday

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* 11. If you have a preference for a specific coach, please indicate your preference below:

Kristen Corcoran

Wendy Walker

Kara Sysyn

Jen McDonald

Kim Golemboski

No preference

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* 1. What is your name?

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* 2. What is your Skidmore email address?

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* 3. What are your pronouns?

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* 4. What is your class year?

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* 5. How did you hear about Wellness Coaching?

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* 6. Were you referred to Wellness Coaching by the Skidmore Counseling Center?

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* 7. Are you a Peer Health Educator (PHE)/Currently training to become a PHE?

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

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* 9. Please tell us a bit about why you want to focus on the topics that you selected.

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* 10. For the remainder of the semester we will be offering Wellness Coaching remotely using Zoom. Please indicate your general availability below. Your coach will be in touch to offer you time options that fit your preferences.

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* 11. If you have a preference for a specific coach, please indicate your preference below:

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* 12. Is there any additional information that you would like to share?