Lyme Assessment Intake Form
    This is a basic assessment to help understand where you are in your recovery. This is not a scored test and there are no wrong answers. Your answers are strictly confidential. You are in the driver’s seat. Each of us is different and unique.  The Lyme Wellness Assessment and Intake Form will help us prepare for your wellness journey.

    Mark each answer with a number from 1 to 5. You can leave an answer blank if you choose. If in question about an answer put a “?” mark in that space. When appropriate you may answer with a yes or no.

    Answer Guide:
    1.   Would equal not at all, never.
    2.   A little.
    3.   Sometimes
    4.   Yes but is not as severe as a 5
    5.   Yes, yes, yes, very much.

    General Information

    Please answer as many of these questions. The more detailed information I have, the more I will able to help.  You determine what you answer and want you share. If you prefer the following questions can be answered in person.  These questions are asked in this format because it will lower the amount of time needed when one on one.

    Personality Questions
    Copyright,  2014 Lyme Wellness D.I.Y. LLC, First edition

    All rights reserved.  This work in whole or part, maybe not be copied nor reproduced without express written permission of Lyme Wellness D.I.Y. LLC.  Make all inquiries to Lyme Wellness D.I.Y. LLC, or cr@LyneWellnessDIY.com.  The information presented does not replace a doctor’s care.  It is meant as information and to help one become educated in one’s Lyme journey.

When you submit the following form you understand the following. 



Patron has been advised and is aware that Coach is not a medical doctor, a nurse practitioner, or any other sort of licensed medical professional. Coaching is limited to verbal and email communication solely to provide information to Patron to assist Patron in communications with her/his medical professionals.

 COACH has a privacy policy and will not discuss Patron’s’ health concerns or any other matter brought up during Patron’s coaching except at Patron’s request and with Patron’s express written permission. However, Patron is aware that no privilege (such as doctor-patient privilege) applies to Wellness Coaching or Wellness Coaches and, if subpoenaed, Coach could be required to testify regarding Patron’s coaching during interrogatories or in a court of law.

 Patron has been advised and acknowledges that Coach will attempt to provide and discuss current and up-to-date information. However, in the field of the Coaching provided, information available changes quickly and unexpectedly and Coach has no responsibility to or liability for being “up–to-the-minute” current on information provided. Coach will use best efforts to remain reasonably current on information. Patron shall obtain more detailed up-to-date information from her/his medical professional. All information, published and non- published materials, forms, substance and methods and systems are the copyrighted, confidential, and intellectual property of Coach. Patron agrees, except to facilitate patron’s communications with medical providers, to hold all information, published and non- published materials, forms, substance and methods and systems private and confidential. Patron will not copy, distribute, share, compromise, modify or alter any of Coach’s information, published or non-published materials, forms, substance, or methods without Coach’s express written permission. Patron shall be liable for all damages, tangible and intangible caused Coach by Patron’s violation of this provision. *