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.Format: (000) 000-0000.
Emergency Contact

PrefixFirst NameLast Name
Emergency Contact #
Please enter a valid phone number.Format: (000) 000-0000.
Interested in
Generally, your availability/optimal time to connect for Coaching sessions would be: (select all that apply)
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
Main Fitness Goal

Other
Biggest challenge when it comes to working out
Other stress factors for me are:

Other
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

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

Do you have current gym access?
If you answered home or condo gym access -- please describe the equipment you currently have (and/or send pictures)
Main Nutrition Goal
Biggest challenge with nutrition
Describe your sleeping patterns in the past 3 months

Current nutrition habits (within the past 2 months)

Rows	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)
Are you interested or are you committed to becoming a better version of you?
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
Instagram - @SuperselfVersion Coaching I.G

Next Gen #Ready Club - Skool Community for 18-27 year olds looking for growth, connection, & discovering their hidden potential.

Website- Wellness, Fitness, & Readiness, Blog & Resources
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Private Coaching & Personal Training intake form