Client Intake Form

Name *

First Name Last Name
Address (Optional - just so I can send gifts or coaching materials)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Email *
example@example.com
Phone Number *
Age
Height
Feet' inches"
Current Weight
LBS
Overall Health Goals: What are your overall health goals? What areas of your health do you currently struggle with? (EX: Nutrition, Exercise, Mindset or all of them) *
EX: Physical goals, performance goals, fitness goals, diet goals, healthy habits, consistency, etc.
Do you have any deadlines, time crunches or events that you’d like your coach to be aware of? Any special events you want to get ready for?

How helpful would you find the following coaching services?

	Somewhat helpful	Helpful	Very Helpful	Extremely Helpful
How helpful would a mobile coaching app (with exercise videos) be for you?
Custom workout program & accountability
Nutrition guidance & accountability
Healthy recipes, meal prep tips, and grocery lists.
Weekly Progress Check-Ins (pics, body measurements, sleep, stress, recovery)?
Weekly mindset development tools (reading assignments, journal questions, and PDFs)
My coaching app actually allows you to upload videos of yourself performing an exercise, so I can provide form feedback. How helpful would that be for you?
1:1 Personal Training Sessions (in person or online)
1:1 Health Coaching Calls (to review weekly progress, action plan, and any questions)

Do you have any injuries, health issues, or are you taking any medications that your coach should be aware of while building your training plan?
For your nutrition plan specifically, do you have any allergies, foods to avoid, preferences or special requests that your coach should be aware of?
Do you currently have or do any of the following regularly? (check all that apply) *

Sweet tooth Eating a lot of snacks Stress eating Emotional eating Late night eating/snacking Not eating all day Eating out a lot because of not having food prepared Going to bed late because of electronic devices None of these Other
From the above, which do you usually struggle with the MOST for your nutrition?
What do you do for work? What are some challenges that your work/job will create for you along this journey? (if any)
What are your typical work hours?
What parts of your current lifestyle do you feel need to change for you to get to your goals and become the person you want to be?

Rate your experience with exercise

What equipment do you have access to? (Check all that apply)

Gym Membership Home Gym (if you selected home gym, please check off all the items you have at home) Free weights (dumbbell/barbells) Cable Machine Squat Rack Resistance bands Kettlebells TRX Suspension Trainer Stability Ball Foam Balance Pad Sliders Will purchase home equipment
On which days/times are you available for a 30 minute coaching call? (check all that apply) *

Tuesday between 6am - 10 am Tuesday between 12pm - 4pm Thursday between 6am - 10am Thursday between 12pm - 4pm Friday between 6am - 10am Friday 12pm - 4pm Saturday 8am - noon Saturday 12pm - 4pm Other
How frequently do you have time to exercise?

1-3 days a week 4-5 days a week 6-7 days a week Up to Coach to decide Other
How would you rate this survey?
FEEDBACK: Do you feel anything was missing from this survey? Was there anything you would take away/ felt was a waste of time?
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