New Client Application

What is your rate for your nutrition?

	0	1	2	3	4	5

0 is Poor, 5 is Excellent

At which frequency you eat at night?

	0	1	2	3	4	5

0 is Never, 5 is Always

At which frequency you eat breakfast?

	0	1	2	3	4	5

0 is Never, 5 is Always

Ho do you rate stress in your life currently?

	0	1	2	3	4	5

0 is Balanced, 5 is Stressed TF out

If comfortable - describe your stressors
How many hours do you sleep?
Do you drink alcohol? If so, describe how much
How often do you exercise per week?
what does your exercise consist of? (ex: crossfit, strength training, bootcamps etc)
how active are you day to day (sitting all day for work, walks, chasing kids etc)
I want to get to know you! In a few sentences tell me about you, work, family, what brings you joy, etc
In a few sentences, what are you learning to gain/learn/change from working with me?
What do you forsee as a challenge(s) to getting started (time, kids, work, stress etc in as much detail as possible?
What are the best days/times for 30min consult, please indicate if you have preference of zoom or phone call:
How did you hear about FUELUP coaching:
WHAT TO EXPECT NEXT:

I will reach out to you via email within 24hours of intake submission to schedule 30 min consult - if live locally , inperson option also available

Check out my website for additional information

www.nutritionwiththeresa.com
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FUEL UP - with Theresa