Wellness Coaching Questionnaire

Wellness Profile!
Please fill in all the fields below to complete the coaching application. Once you complete the application, I will reach out to you to schedule a call so we can discuss your fitness & nutrition goals and see if this is a good fit.
Full Name*

First NameLast Name
Email*
example@example.com
Phone Number*

Area CodePhone Number
Age*
years
Do you promise to answer all the questions below honestly?

YesNo
List 3 outcomes you want to achieve in the next months while working with me. Be specific!
Are you willing to walk away from tempting distractions that could inhibit your progress?

Yes !I am, however it will be difficult.I am not sure. I have tried and failed in the past.Probably not.No, I deffinately can not.
What have you tried before and why did it not work for you?
What or who could be holding you back from reaching your desired outcomes? Be specific
What was your greatest success with achieving a health related goal in your life? Why did you succeed?
What tools or assistance could I provide for you that would help to improve your chances of succeeding? Be specific.
If I provide you with a path to reach your desired outcome, are you financially prepared to invest in Your health to get the results you desire?

YES I am ready!Honestly, I am not sure.Probably not.
When you achieve your desired goal will you let me use your testimony and story to help motivate and encourage others to take the same steps you have taken?

Yes, Of course!I'll have to think about thatAs long as my face is not used.No, I wouldnt like that
When you achieve your desired goal will you let other people know where you received your fitness coaching and refer? Will you help others find that same joy in being fit?

Yes, AbsolutelyNo I will not do that.
Do you promise to committ to yout fitness and nutrition goals and follow the directions to the best of your ability?

YESNo
Do you promise to be committed to your fitness and nutrition goals and follow directions to the best of your ability?

YesNoOther
Do you have access to a gym or equipment at home for home workouts? (Dumbbels, Free weights, booty bands, resistance bands, exerice ball, squat rack, etc)

YesNo, but willing to invest
Any food related issues? (Gluten, dairy etc)
Option 1Option 2Option 3
For nutrition- how many meals per day do you prefer? ( including snacks)

3 meals4 meals5 meals
Please rate your readiness for change.

12345678910
Why?
What do you need the most help with?

AccountabilityJust starting!I've hit a plateau & I need to change thatOther
How do you prefer to be contacted?

CallTextEmailOther
I am so excited that you decided to reach out to me to help you with your wellness goals! I can't wait to work with you! I'll reach out within 24 hours!
I look forward to serving you. Please let me know if I can help you in any other way.
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Wellness Profile!