121 Coaching

121 Coaching
Your Details
Name *

First Name Last Name
Address *

Street Address

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City

Post Code
DOB eg; 30/04/1980
Email *
example@example.com
Phone Number *
About You
What is your goal and vision? (tick all that apply)

Weight loss Change body shape Feel stronger Build muscle Change mindset towards exercise Change mindset around how I feel about myself Prevent illness and disease Improve cardiovascular health Feel fitter Training for an event Develop a better relationship with food Develop a better understanding of exercise
If your goal is specific to weight loss or in being a certain size, please add the details below (if not related to weight loss or body shape change leave blank)
Is there any of the following you are finding challenging or are experiencing at the moment? (tick all that apply)

Self esteem Lack of confidence Stress Anxiety Low mood or feeling down Feeling like something is holding you back Relationships Feeling lost Feeling demotivated Loss of energy or drive Disturbed sleep Body image Love for yourself None of the above
What will it give you when you reach your goal/vision?
What do you need from a coach? (tick all that apply)

Help with motivation Learn how to exercise Guidance with nutrition To be challenged Accountability Need a change from current program/plan To help see results physically To help make changes to mindset
Do you currently take part or have you taken part in the last 12 months? (tick all that apply)

Gym member Group Exercise/Classes Sports club Workout at home Movement based hobbies
Do you track food intake currently or have you tracked it before?

Yes No Tracked previously
Do you experience any obstacles with food? (tick all that apply)

Over snacking Emotional eating (tired, sad, happy, bored, upset, stressed etc) Eat as a habit and not when hungry Portion control Don't plan meals Not sure what to eat Avoid eating out as never know what to order Don't enjoy cooking or preparing Lifestyle Work Managing meals around the family
How physically active on average are you during any normal day?

Active all day Regularly active Fairly active A little active Not active at all
What would you say your hardest habit or behaviour is to change is currently? (doesn't have to be food related)
Are there any habits or behaviours you want to let go of?
How would you rate stress levels generally?

Highly stressed Random bouts of stress Rarely stressed Never stressed
How would you rate your typical energy levels?

Always energised Fairly energised Low energy No energy at all
About Your Health
Q1 Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?

Yes No
Q2 Have you ever felt pain in your chest when you do physical exercise or at rest?

Yes No
Q3 Have you been told by a doctor that you have high blood pressure?

Yes No
Q4 Do you often feel faint, have spells of severe dizziness or have lost consciousness?

Yes No
Q5 Have you ever suffered from unusual shortness of breath at rest or with mild exertion?

Yes No
Q6 Has the doctor ever said that you have a bone or joint problem, such as arthritis, that has been aggravated by exercise or that may be made worse by exercise?

Yes No
Q7 Are you currently on any prescribed medicines that may affect your ability to exercise?

Yes No
Q8 Are you pregnant or have you had a baby in the last 6 months?

Yes No
If you have answered Yes to one or more of the above questions 1-8, please confirm by ticking Yes below that you have consulted your GP and they did not advise that you are not able to take part in any form of physical activity and that you have been cleared to partake in the exercise programme. If you have not answered Yes to any of questions 1-8 above please tick N/A *

Yes N/A
Tick the box below to certify and confirm that your answers to the questions above are true and to the best of your knowledge. That you understand and agree that it is your responsibility to inform my coach of the conditions or changes in your health, now and on-going, which might affect your ability to exercise safely and with minimal risk of injury.
Tick Yes to confirm when you have read, understood and agree the above *

Yes
Terms And Conditions
The purpose of a reframe and train plan is to help you to achieve your goals. Your plan will be based upon your present activity/exercise levels and the goals that you wish to achieve. You will experience some feelings of exertion during each activity session and your breathing and heart rate will increase as a result of these activities, as would be expected from physical exercise of this type. As your fitness improves, you will participate in more vigorous levels of activity, if this is part of your goal, but these should remain within your capabilities. All activities will be explained and demonstrated to you but please feel free to ask questions about anything you wish at any time during the session.

During your sessions with your coach you will be supervised via a video link, you will be responsible for your own safety. If, at any time, you feel undue pain or excessive discomfort stop the activity and inform your coach of your symptoms. You are free to withdraw from any activity at any time.

Reframe therapy based support covers a wide range such as confidence, self esteem, anxieties, low mood, stress, relationships, life challenges, issues preventing you from achieving your ambitions and developing a better understanding of problems.

In accordance with my professional code of conduct the protection of a clients privacy is very important and all information discussed during the sessions will be held confidentially.

The number of sessions will be pre agreed with your coach and pre payment will need to be made prior to the date of the first session.

24 hours notice of cancellation is required for any session, if cancelled within 24 hours full payment will be incurred. If you do need to cancel or amend a session contact your coach at least 24 hours before the session start time where you will be able to transfer that particular session once. If the transferred session needs to be cancelled full payment for the session will be incurred. In the unlikely event of your coach being unable to continue with the training, you will be offered a full refund on any remaining sessions/package.

If you are late for your online session, the session will be reduced in accordance with that time. If you are more than 15 mins late, your coach may choose to cancel the session and you may lose the session. In this circumstance no refund will be made.

Once sessions have been paid they have a 6 month date of expiry, pre paid sessions may be extended by the discretion of the coach.
Tick Yes to confirm when you have read, understood and agree the above *

Yes
Disclaimer
During the sessions I:

Will make sure the area I am using for the session is appropriate i.e non slippy floor and an appropriate area to store and workout with weights in. I will check that the weights i.e dumbells are safe and ready for use prior to each session starting, they are my responsibility to maintain the safe use of ongoing. I will wear good grip footwear and appropriate clothing so that I am able to fully take part.

Understand that all information expressed or shared within a session or on website or social media sites are for information purposes only and does not constitute medical, nutritional, dietary or any other medical advice. It is not intended to replace or substitute any advice of a qualified doctor, nutritionist, dietician or qualified physiotherapist. Use of the programs, advice and information presented is at the sole choice of myself. That all views expressed by the coach are opinion based and assumes no responsibility or liability for any errors or omissions in the content provided.

Will be responsible for my own health and safety during the session. If I sustain an injury while participating in the fitness programme. I acknowledge that my coach is not responsible, except where the injury was caused by the gross negligence or intentional act of my coach.

Understand that I need to inform my coach if I do not consent to any of my submitted before and after photographs in being used on Move With Energy Move With Mindset website and social media. If required it will be used in an appropriate manner, to share the successful results of clients and to help promote services.

Understand that there are inherent risks in participating in a programme of strenuous exercise. If I sustain an injury while participating in the fitness programme. I acknowledge that my coach is not responsible, except where the injury was caused by the gross negligence or intentional act of my coach.

Understand the results of any coaching plan aren’t guaranteed and my progress depends on outside of the sessions aswell as me taking an active part during both elements of the sessions.
Tick Yes to confirm when read, understood and agree with the above *

Yes
Please select which preferred method of contact for session

WhatsApp Video FaceTime Zoom
One you are happy that you have completed the form above click the submit button below

I will be in touch with you soon to discuss your goals and start getting to work on your personal plan

Wishing you a warm welcome, I can't wait to get you started on your journey

My Products

1x 25 minute online one to one exercise coaching session £ 25.00 GBP

1x 25 minute effective exercise for the body based coaching session

1x 50 minute online one to one body and mind coaching session £ 45.00 GBP

1x 50 min exercise and mindset coaching session for helping to change both body and mind

1 x 25 minute online one to one Mindset coaching session £ 25.00 GBP

1 x 25 minute mindset changing coaching session

Total £ 0.00 GBP

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