Client Inquiry Form

Name *

First Name Last Name
Phone Number *
Email *
Location *

Street Address Line 2

State

Country
If referred to me, who may I thank for sending you my way?
Why have you chosen to reach out to me for help in improving your health, nutrition and fitness? *
What nutrition and fitness goals are you currently working toward or would like to work toward? *
How long have you been working on achieving these goals? *
If, six months from now, you were to feel exactly how you want to feel in your own body, what would that look/feel like? *
What challenges do you believe have prevented you from reaching your goals? *
Do you currently track your food intake? If so, how to do you record your food intake (pen and paper, MyFitnessPal, Lose It etc.)? *
If asked to do so, would you be open to tracking your food intake? *

Yes No
If no, please explain why.
Do you weigh yourself regularly? *

Yes No
If asked to use a scale, would you be open to weighing yourself once a week or every day? *

Yes No
If no, please explain why.
How committed are you to achieving your goals? *

1

2

3

4

5

6

7

8

9

10

1 is Meh..., 10 is LETS GO!
Please explain why you chose the number regarding your level of commitment. *
Are you willing to make a financial commitment if you see we are a good fit to help you reach your goals? *

Yes No
Nutrition coaching is both a time and financial commitment. Will there be any other individuals involved in the financial decision-making component regarding nutrition and fitness coaching? *
If I am able to build a compelling road map to help you achieve these goals, are you ready to commit to nutrition coaching? *

Yes No
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