Health Coaching Session Note (Functional Medicine)

Date of Service: [date]    Session Duration (minutes): [duration]    Modality: [in-person / video / phone]    Client: [client name]    Coach: [coach name and credentials]

Session: [session number and series descriptor]    Time Since Last Session: [time interval]

Chief Coaching Focus

[Client's stated agenda and negotiated focus for today's session] (Format as 1–3 concise bullet points or a brief paragraph. Use client-centered language.)

Progress Since Last Session

(For first sessions or when prior goals are unavailable: "No prior coaching goals on record; established baseline today.")

• [Prior goal or behavior] — [met / partially met / not met]

  • [What helped or hindered completion]
  • [Barriers encountered: practical and/or emotional, in coaching terms]
  • [Client insights about what worked or didn't]
  • [Client-reported symptoms or self-tracked metrics relevant to this goal] (Include only if applicable)

• [Additional prior goal] — [met / partially met / not met] (Include additional goals only as applicable)

(Scope-of-practice: When client mentions diagnoses, labs, or medications, document using "Client reports…" language. Do not imply coach interpretation of medical data.)

Readiness & Motivational Assessment

• Stage/readiness: [considering change / preparing / actively implementing / maintaining / ambivalent]
• Importance: [0–10] — [client's rationale, including "why not lower"] (Include only if assessed)
• Confidence: [0–10] — [what would raise confidence] (Include only if assessed)
• Values connection: [1–2 key client values in their own words linking to target behavior]
• Change talk themes: [desire / reasons / need / ability / commitment statements]
• Sustain talk/ambivalence: [hesitations or competing priorities] (Include only if present)
• Coaching approach: [techniques applied, e.g., reflections, affirmations, scaling, decisional balance]

Goals & Action Plan

(Limit to 1–3 goals per session. Goals must be observable and trackable.)

• Goal 1: [Behavioral goal in client-centered language]

  • Action steps: [what / when / where / frequency]
  • Tracking: [how completion will be measured]
  • Confidence: [0–10] (Include only if assessed)
  • Barriers & if–then plan: [anticipated obstacles and contingency actions]
  • Support/resources: [people, tools, environment changes]

• Goal 2: [Behavioral goal] (Include only if applicable)

  • Action steps: [details]
  • Tracking: [details]
  • Confidence: [0–10] (Include only if assessed)
  • Barriers & if–then plan: [details]
  • Support/resources: [details]

• Goal 3: [Behavioral goal] (Include only if applicable)

  • Action steps: [details]
  • Tracking: [details]
  • Confidence: [0–10] (Include only if assessed)
  • Barriers & if–then plan: [details]
  • Support/resources: [details]

Education/resources provided: [topic and client response] (Include only if provided)

Care coordination: [messages to care team, referrals] (When medical topics arise: "Coach encouraged client to discuss [topic] with prescribing clinician.")

Follow-Up & Accountability

• Between-session plan: [tracking tool, check-in method and cadence]
• Next review focus: [what will be reviewed next session]
• Next appointment: [date/time or scheduling plan]
• Contact guidance: [when to contact coach vs. medical team for concerns]
• Safety concerns: [red flags identified and actions taken] (Include only if applicable)

(Use neutral language suitable for client access. Distinguish client-reported information from coach observations. Omit any section not addressed rather than inserting generic text.)