SSVnewclientintakeform

Private Coaching & Personal Training intake form

Devon James, Executive Wellness & Performance Coach @SuperselfVersion
Name*

PrefixFirst NameLast Name
Date of Birth*

MonthDayYear
Date
Email*
example@example.com
Address*

Street Address

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Emergency Contact *

PrefixFirst NameLast Name
Emergency Contact #*
Please enter a valid phone number.
Interested in*

Face to Face Coaching 1 on 1Online Wellness & Fitness 1 on 1Online Group Wellness & Fitness with 1 on 1 hybrid for support (custom programming, goal setting, challenge, accountability, & community)
Generally, your availability/optimal time to connect for Coaching sessions would be: (select all that apply)*

Evenings & weekendsWeekday morningsWeekday afternoonsWeekendsSchedule changes weekly
Define what success would look and feel like after our first 3 months of working together*
i.e. Success would be if I feel more confident in myself, get back to a healthy weight, lifestyle, and...
Have you hired a Personal Trainer and/or other Coaches before? If so, what type and how was your experience?*
i.e. "Yes, Personal Trainer/Nutritionist/Life Coach I liked ___ and did not like ___ " or "first time"
The best thing a Coach could do for me right now is to:*
i.e. Guide, support, listen, motivate, provide accountability, help me develop sustainable routines for...
What habits are currently pulling away from your optimal recovery and overall well-being? *
i.e. Going to bed late because of... Eating unhealthy whenever I... Overcommitting myself.. Lack of goals or social health..
I am primarily reaching out with interest in*

Personal Training & Physical ResultsLife & Wellness Coaching (healthy habit building, personal goal setting, accountability, guidance, active sound-boarding, connection, & support)Martial Arts (Muay Thai, Boxing, Kickboxing)Other (i.e. Team training, speaking event, Sport training)
Main Fitness Goal*

Weight loss & muscle toningStrengthen, tone, & shape (build lean mass)Increased athletic sport performanceIncreased confidence, energy, & movement patternsIncrease weight & build muscle massMarital arts focused (Muay Thai, Boxing, Striking)Other
Biggest challenge when it comes to working out*

I'm not sure of what I should be doing with my workoutsI lose motivation and tend to fall off track quicklyI struggle to maintaining consistency/making time to workoutHave hit a plateau with my current routine/results/excitement for my workoutsI haven't found a way to enjoy working out yet
Other stress factors for me are:

My work is very stressfulI have trouble talking to myself kindlyI need help with goal setting & staying motivatedI don't know how to achieve the goals I want to achieveI overcommit myself to too much at onceI have trouble with anxiety and/or depressionA specific current/past relationship is weighing down on meI let my thoughts spiral easilyI feel a lack of purpose, uncertainty, and/or motivationOther
If you have injuries that affect your workouts/movement patterns/recovery, please describe
Any medical ailments (i.e. diabetes, thyroid issues, previous heart attacks, stints, fibromyalgia, etc.)

Physical activity in the past 2 months*

	None	1-2x/week	3-4x/week	< 4x/week
Cardio workouts
Weight lifting
Stretching/Yoga
Sport activity

Do you have current gym access?*

Box Gym (i.e. Goodlife, LA Fitness, Movati)Hot Yoga StudioGroup fitness studioCondo or home gymNo gym access or home equipment currently
If you answered home or condo gym access -- please describe the equipment you currently have (and/or send pictures)
Main Nutrition Goal*

I'm looking to eat healthier and lower my weightMy goal is to eat healthier and increase my weightHappy with current weight range -- I just want to adopt healthier nutrition & feel more energetic while seeing physical progressMy Nutrition habits are very healthy, sustainable, and conducive to my goalsOther (i.e. rebuild immunity, work around allergy, learn to cook, etc.)
Biggest challenge with nutrition*

I don't know how to eat properly in order to reach my goalsI eat out oftenI struggle to make time to cook or eat SporadicallyPortion control -- I eat too muchI don't think I eat enough / skip meals oftenI don't enjoy cookingI tend to "yo-yo diet" (super strict dieting then fall off completely & repeat...)Other ( i.e. food allergies, substance abuse, digestive issues)
Describe your sleeping patterns in the past 3 months*

Very good 7-8.5 hours rested and energized7-8.5 hours but not feeling restedunder 7 hours per night average+8 hours still not rested or feeling energeticAll over the place, no consistency

Current nutrition habits (within the past 2 months)*

	Very unhealthy	Unhealthy	Somewhat healthy	Healthy	Very Healthy
Water intake
Eating out
Cooking
Alcohol, cigarettes or other substance use

I currently (or previously) use supplements or other health products to assist with my workouts & well-being (i.e multi-vitamin, protein, BCAAs, Creatine, collagen, etc.)
Describe what you currenty (or previously used) and your experience
What is your typical day like for nutrition?
i.e. I eat breakfast/lunch/dinner at __ time, I eat on the g, I cook and eat very clean...
I am comfortable with (for fitness clients)*

Taking progress pictures and sharing on social mediaTaking progress pictures for later comparisons, but no sharing at the moment (or face blurred)Neither of the above, but open to progress pics/tracking for own future comparison
Are you interested or are you committed to becoming a better version of you?*

Not sure - I need help getting to that point mentallyInterested - I'd like to, I'll do it when it's convenient, let's see what happensCommitted - I'm ready to do what needs to be done-- to set goals, to pursue & continue-- I just need some help, support, guidance, or purely accountability to stay the course
Who are your most positive friends that have similar goals to you? Keep them close. Cherish them. If this part is empty-- that's okay too-- that's why we're here.
List 1-3 names & send them a message or call of appreciation
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Private Coaching & Personal Training intake form