1-1 Nutrition Coaching Application

1

Before you begin, please note that I am unable to work with you if you are currently in treatment for an eating disorder.

Currently, 12-week 1-1 coaching starts at $2100+. If that is not an option for you at this time, please see my group coaching program.

2

Steph is committed to building an anti-racist and diverse, equitable, and inclusive business. Does this align with your personal values?* This field is required.

YesNo

3

What is your first and last name?* This field is required.Type your full name

4

What are your pronouns?* This field is required.ex: (she/her), (he/him), (they/them), etc

5

What is your email address?* This field is required.

6

What is your phone number?* This field is required.

Area Code

Phone Number

7

What city and state do you live in?* This field is required.

8

What are you most excited about accomplishing by working with a coach?* This field is required.

9

What are you struggling to solve and why is a solution for it important to you?* This field is required.

10

What's working about your nutrition? What's not working about it?* This field is required.

11

What's working about your training/exercise? What's not working about it?* This field is required.

12

Are you satisfied with your eating patterns?* This field is required.

YesNo

13

Do you ever eat in secret?* This field is required.

YesNo

14

Does your weight affect the way you feel about yourself?* This field is required.

YesNo

15

Have any members of your family suffered with an eating disorder? (If not sure, mark "no")* This field is required.

YesNo

16

Do you currently suffer with or have you ever suffered in the past with an eating disorder?* This field is required.

YesNo

17

Have you ever been formally diagnosed with an eating disorder? (ex: anorexia, ARFID, binge eating disorder, bulimia, EDNOS/OSFED, orthorexia, etc)* This field is required.

YesNo

18

In the past year, have you been diagnosed with a major mental or physical health issue?* This field is required.

YesNo

19

What would be your ideal situation in 6-12 months? Describe in as much detail as you can.* This field is required.

20

How did you hear about me? Anything else you'd like me to know?