Coaching Interest Form
Personal Information
Name
*
First Name
Last Name
Gender
*
Female
Male
Phone Number
*
Please enter your best contact phone number.
Email
*
example@example.com
My preferred contact method is:
*
Email
Phone call
Text
No preference
My preferred time of contact is:
*
9:00 a.m. - 12:00 p.m.
12:00 p.m. - 4:00 p.m.
4:00 p.m. - 7:00 p.m.
No preference
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Goals
What are your wellness goals? (Check all that apply.)
*
Become more active
Better sleep
Improve overall health
Improve physical appearance
Lose weight
Maintain weight
Manage stress
Other (Please explain below.)
If you selected "Other" above, please explain here.
Share your concern(s) regarding making beneficial changes. (Check all that apply.)
*
Fear of failure
Inconsistency
Lack of motivation
Lack of time
Lack of willpower
Other
If you selected "Other," please explain here.
Briefly describe your current diet.
*
(Example: Red meat 4x a week, vegetables 2x a week, 4 cups of water per day, etc.)
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Stress Management
How frequently do you exercise?
*
1 - 2 times per week
3+ times per week
Exercise is not (currently) part of my schedule.
How do you manage stress?
*
(Read, journal, dance, play sports, etc.)
How many hours do you normally sleep at night?
*
Other
What are your expectations from the coaching session(s)?
*
On a scale of 1 - 10, what is your readiness to change in order to reach your desired results?
*
(Example: 6)
When available, would you prefer in-person or virtual coaching?
*
In-person coaching
Virtual coaching
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I understand that, for my safety, I am advised to seek advice from a medical doctor/health care provider BEFORE making any changes to my diet and physical activity habits.
*
Yes, I do.
No, I do not.
Submit
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