Evexia Health & Wellness Coaching Interest Form

1

Email address* This field is required.

example@example.com

2

First Name* This field is required.

3

Last Name* This field is required.

4

Phone Number

5

Preferred method of contact* This field is required.

Email

Phone

Video call

6

When is the best time for you to chat?* This field is required.

Morning

Afternoon

Evening

7

What time zone are you in?* This field is required.

9

Age* This field is required.

25-39

40-49

50-59

60 or older

10

Which program(s) are of interest to you?* This field is required.

1:1 (Individual Coaching)

Group Coaching

Monthly Accountability Coaching

Self-guided courses

I'm not sure

11

Which best describes you?* This field is required.

I need some guidance and accountability so I can improve my general health

I've tried to diet and exercise on my own but I can't seem to get the results I want

I exercise regularly but my diet isn't healthy

I know what to do but I'm unable to do it consistently

I don't know much about healthy eating and need help with the fundamentals

I just want to lose weight

Other

12

What is your Goal? (Choose all that apply)* This field is required.

Lose weight/fat

Increase strength

Be healthy so I can be around for my kids & grandkids

Increase my energy

Improve the overall quality of my life

Look good naked

Other

13

What are you looking for from a Coach?* This field is required.

I want ongoing 1:1 help with nutrition, exercise, and accountability

I need help getting started then I'll go at it on my own

I would like to work in a group setting and meet others in my situation

Other

14

On a Scale of 1-10, how committed are you to achieving your goal?* This field is required.