KiwiSoul Wellness — New Client Intake

I. About You

First Name

Last Name

Email Address

Phone Number (WhatsApp — we may reach out via call or text)

Date of Birth

Biological Sex

Where Are You Based in Cabo?

How Did You Hear About KiwiSoul?

II. What Brings You to KiwiSoul

Your Main Wellness Goal

How Important Is This Goal Right Now?

1 10 7

Not urgentTop priority

Success in 90 Days Looks Like…

III. Lifestyle Snapshot

Hours of Sleep Per Night

Sleep Quality

Exercise Frequency

Types of Movement You Enjoy

Daily Water Intake

Current Eating Habits

Alcohol Frequency

Never Rarely (special occasions) 1–3 times/week Most days

Main Source of Stress Right Now

Work / career Finances Relationships / family Health concerns Lifestyle / environment change Not sleeping well I don’t feel particularly stressed

Overall Stress Level

1 10 5

Very calmExtremely stressed

IV. Health Background

A note before we continue — KiwiSoul Wellness provides wellness support only. We do not diagnose or treat medical conditions. These questions help us understand your history and refer you to the right licensed providers when needed.

Do You Currently Work With a Physician or Specialist?

Bloodwork or Labs in the Past 12 Months?

Currently Taking Medications or Supplements?

No need to list here — you can share details on your discovery call.

Anything We Should Know Before Your Session?

Helps us ensure your plan is appropriate and connect you to the right provider if needed.

V. Session Preferences

Session Format

In-person in Cabo Video call Either works

What Matters Most in a Wellness Program?

Results — outcomes are everything Feeling supported & accountable Speed — I want change fast Affordability Simplicity — easy to follow

Anything Else We Should Know?

VI. Acknowledgment

KiwiSoul Wellness provides wellness education, lifestyle guidance, and supportive care coordination designed to help individuals better understand and optimize their overall wellbeing. Our approach is rooted in functional wellness principles, health education, and personalized lifestyle support. Our team are professionally US board certified, trained and experienced in health and wellness disciplines, and hold active US licenses. Services provided in Mexico are non-medical in nature and are not intended to diagnose, treat, cure, or prescribe for any medical condition. Information shared is educational and wellness-focused only. Individuals experiencing medical concerns, urgent symptoms, or requiring medical treatment should consult a licensed healthcare provider in their region.

New Client Wellness Intake

Thank You!