RECLAIM YOUR CONFIDENCE APPLICATION

RECLAIM YOUR CONFIDENCE APPLICATION

Filling out this form is NOT a commitment to working together. This form just allows me to learn more about you and determine whether we are a good fit! All submissions are confidential. Please provide as much detail as possible. If I feel like we are a good fit, I will reach out within 24-48 hours with pricing and next steps. LET’S GO 👇🏻
Name

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
What city / time zone are you in?
What is your Instagram name?
What are your specific goals? (This can be anything — fitness, nutrition, lifestyle, etc.)*
What have been your barriers to reaching your goals? *
What have your tried so far to help you reach your goals? *
On a scale of 1-5, how important is this goal to you?*

1

2

3

4

5

1 is Not super important , 5 is EXTREMELY important
What kind of coaching are you interested in?*

Nutrition only: macro calculations, macro guide, 1:1 weekly check ins, daily accountability support, biofeedback trackingFitness & nutrition: macro calculations, macro guide, custom workout programming, 1:1 weekly check ins, daily accountability support, biofeedback trackingWorkouts only: weekly workouts custom to youCustom Macro CountI don't know yet
How long would you like to be a part of "Reclaim Your Confidence"?*

4 months6 monthsI just want a custom macro count
Are you now or have you ever received professional treatment for an eating disorder or a similar diagnosis? **

YesNo
Do you have any health conditions (PCOS, hyperthyroidism, etc) I should be aware of? *
Age, height, weight? *
What do you do for work? Is this job sedentary, moderately active, highly active/on your feet all day? *
Do you have a smart device or step counter? How many steps do you average daily (if you know)? *
Do you have experience tracking macros? Select the answer that sounds most like you:*

I have never tracked macros / caloriesI have some experience tracking calories, not macrosI have 0-3 months of experience tracking macrosI have 6+ months of experience tracking macros
What is your average daily calorie intake (if you know)?
Hiring a 1:1 coach is both a time commitment and financial commitment - but it will get you results and help you find the freedom you’re looking for. Are you prepared to make a financial investment in yourself?*

YesNot right now
How did you find me? *
IG, FB, a certain FB page, friend referral, etc.
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