WELLfix
“Your personal fix of wellness”
Full Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
E-mail
*
example@example.com
Give me 100-200 about yourself and what motivates you.
How long have you known me ?
Less than 6 months
More than 6 months
More than a year
More than 2 years
Other
What is your overall goal and the time frame you want to accomplish it?(for example: “I want to lose 20 pounds in 12 weeks..” or it could be internal such as “I want to be able to run in the yard with my kids”
What would be the most important criteria for your success if we worked together?
What have you tried in the past and why hasn’t it worked? What’s stopping you from being successful?
On average how much do you spend on coffee in a week?
On average how much do you spend on energy drink a day?
On average how much do you spend on eating out in a week?
On average how much do you spend on alcohol a week?
How much money do you spend on tobacco or nicotine products a week?
On a scale of 1-10 how motivated are you to reach your goals? 10 being you want it more than anything and 1 being you are indifferent about your health.
We ONLY work with people who are ready to invest in themselves! Are you READY RIGHT NOW to make that decision?
Yes
No
Are you willing to invest 200+ a month in yourself ?
Yes
No
Does your spouse or significant other support you in being a healthier you?
Yes
No
If we worked together what would you expect from me?
Spots on my team are limited! What do you think makes you a good fit for The FIT foundation and my personal mentorship?
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