Jess Leech Personal Training
Bespoke coaching application form
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (00000000000).
Date of birth?
*
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Gender
*
Male
Female
Height
*
cm
Weight
*
Kg’s
What is your main reason for applying to bespoke coaching today?
*
eg; fat loss, muscle gain, fitness
What is your short term goal?
*
Something you’d like to achieve in 4-6weeks
What is your medium term goal?
*
Something you could achieve in 4-6months
What is your long term goal?
*
Something you would like to achieve in at least 12 months time eg; eating habits, x’KG’s loss, food relationship
What is it that motivates you to make the change now?
*
Have you ever followed a gym programme before?
*
Yes
No
Are you currently a member at a gym?
*
Yes
No
If you previously answered yes to being a gym member please state below what your typical week at the gym consists of?
eg; circuit classes, gym programme, random workouts, hiit
Are you currently employed?
*
Yes
No
Do you have any diagnosed health conditions?
*
Do you have any injuries?
*
Do you smoke?
Yes
No
What is your daily alcohol intake?
Low
1
2
3
4
High
5
1 is Low, 5 is High
What is your daily activity level?
Less that 5k steps
1
2
3
4
Over 10k steps
5
1 is Less that 5k steps, 5 is Over 10k steps
My bespoke coaching packages start from approx £70 per month. Are you ready to invest in yourself?
*
Yes
Not yet
Where did you hear about me?
*
How would you prefer me to contact you?
Email
Telephone (whatsapp)
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