Online Coaching Consultation Form

Full Name*

First NameLast Name

MaleFemaleTransgenderPrefer not to say

Date of Birth*

MonthDayYear

Age

years

Height

ft

Weight

If unknown that's okay

Phone Number

Area CodePhone Number

Email

How do you prefer to be contacted?

What do you do for a living?

none(seated only)Moderate (light activity such as walking)High (heavy labor, very active)

Do you follow a regular working schedule, do you work days, afternoon or nights?

How often are you physically active?:

If you have any diagnosed health problems list the condition(s) and/or medications?

Would you require any face to face sessions prior to being independent online?

If you have any injuries, please list them.

YesNo

What are you goals?

Why?

TImeline for achieving your goal/coaching

Rows	8 WKS	16 WKS	24 WKS	32 WKS	40 WKS	1 YEAR
NOW

YesNoNot enough

YesNo

How often are you willing to exercise each week?

Please Choose

YesNoOnly Progress

YesOnly for PT to seeOnly for personal trackingNo

What are your expectations on me as your Coach? (Please list as many as possible)

*Please note my coaching aim to to eventually allow so much progress that you can be independent with tracking food, training with good form and happy with your goals and asethetic. In order for this to happen we will be using a few apps (that are all free for you to use) Firstly, the App 'Trainerise' to have all our programs there ready and easy to use once you go the gym with videos, and data entry for weights etc.

Secondly, 'My Fitness Pal' for tracking food according to your macros and calorie intake, this will also track nutritional content such as fibre and is a great tool when building muscle or dieting. Although some people do not feel comfortable tracking this is preferred when starting a new training block in order to track your metabolism, fatigue and nutrition. If you do not wish to do this we could work off a meal plan instead.

Thirdly, Whatsapp for communication and to store photos (if you wish). This allows an open line of communication and you are welcome to check in DAILY with me. Your protocols will be set every Sunday, your check in every Friday (regarding how you went that week). I only have a few coaching clients at a time, so that I am fully available to support your progress and change.

*My experience as a Physio and also in the fitness industry allows me to offer an effective, affordable and safe way to reach your goals. With the ultimate idea to get your training consistently, staying motivated and injury free.

1.) FACE TO FACE -CANCELLATIONS Cancellations should be made at least 24 hours in advance of a scheduled session. Sessions cancelled less than 24 hours in advance will be charged in full to the client. 2.) LATE ARRIVALS Each session shall be 1 hour in length. Sessions will not be extended (unless time is available) due to the lateness of the client or due to interruptions caused by the client. 3.) ALL THE INFORMATION I HAVE GIVEN IS CORRECT All the information on this form is correct and to the best of my knowledge. I have sought and followed any necessary medical advice. I understand that all the information given will be kept confidential.

YesNo

Online Coaching Consultation Form

Email: theresestegley@gmail.com Instagram: therese_physio