Get started with 1:1 Coaching
I can't wait to learn more about how we might be a great fit to work together.
PERSONAL INFO
Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Age
E-mail
example@example.com
Instagram Handle
ex: charlottepilates_studio
Preferred Gender
Male
Female
Other
Birthdate
-
Month
-
Day
Year
Date
Height & Weight
What do you do for work?
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SECTION 2: HEALTH HISTORY
What is your Goal signing up for the coaching program?
Fat Loss
Body Recomposition
Muscle Gain
Better Relationship with Food
Gut Health Issues
Build Healthier Habits as a Whole
Have you been officially diagnosed with Hashimoto’s?
Yes
No
Suspected, but I haven't been diagnosed
If officially diagnosed, when did you receive your diagnosis?
Are you currently on thyroid medication?
Yes
No
If yes, which one and what dosage?
Do you have any other autoimmune conditions or major diagnoses?
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SECTION 3: CURRENT SYMPTOMS & CHALLENGES
What are the top 3 symptoms you’re currently struggling with?
(e.g. fatigue, weight gain, brain fog, bloating, joint pain, mood swings)
How long have your been struggling with these symptoms?
On a scale of 1-10, how much are your symptoms interfering with your quality of life?
Not at all
1
2
3
4
5
6
7
8
9
Greatly
10
1 is Not at all, 10 is Greatly
Have you worked with any practitioners, coaches, or done any protocols before?
Yes
No
If yes, what worked? What didn't?
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SECTION 4: Nutrition & Lifestyle
Are you currently gluten free and/or dairy free?
Gluten-free
Dairy-free
Both
Neither
Trying, but struggling
What does a typical day of eating look like for you?
How often do you cook at home?
How many days per week do you exercise and what kind of movement do you do?
Do you track your food or macros?
Yes
No
I've tried, but it was overwhelming
I'm open to learning more
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SECTION 5: MINDSET & COMMITMENT
Why is it important for you to heal right now?
What goals would you LOVE to achieve over the next 3–6 months? (Think: physical, emotional, energy, mindset, etc.)
What do you feel is holding you back from reaching your goals?
On a scale of 1–10, how committed are you to investing time, energy, and resources to heal your body and feel like yourself again?
Not really
1
2
3
4
5
6
7
8
9
Very Committed
10
1 is Not really, 10 is Very Committed
Are you looking for... (check all that apply)
1:1 Mentorship
Group Support
Self-Paced Guidance
Not sure yet
If we both feel it’s a good fit, are you ready to financially invest in a high-touch program to support your transformation?
YES - 100% Committed and I'm ready now
Possibly, I need more details
I'm not 100% ready at this time
APPLY NOW!
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