Customized Coaching Application

Full Name* This field is required.

Email Address* This field is required.

What is your preferred method of contact?

Age? * This field is required.

What are your health and fitness goals? Tell me where you are now and where you want to be; don't be scared to dream big and get specific!

What are the biggest hurdles preventing you from reaching your goals and why do you want to change now?

What have you tried in the past? If you have had weight loss surgery please note in this section date and type of surgery.

How do you feel?* This field is required.Check all that apply and please feel free to elaborate in the "other" section

feeling great!

tired all the time

sluggish

anxious

depressed

stressed

How is your sleep?* This field is required.Check all that apply and please feel free to elaborate in the "other" section

perfect!

Not perfect but am generally sleeping well

trouble falling asleep

trouble staying asleep and cannot go back to sleep

trouble staying asleep but have no trouble getting back to sleep

Gut Health Quiz* This field is required.Check all that apply and please feel free to elaborate in the "other" section

I poop once or more per day

I poop most days

I poop every other day

I poop less than every other day

I am often constipated

I often have loose stools

I experience gas

I experience bloat

I experience heartburn and/or reflux

I have been diagnosed with IBS

I have an autoimmune disease

I need a stimulus/laxative to have a bowel movement

I experience nausea often

Do you have a period?* This field is required.Check all that apply and please feel free to elaborate in the "other" section

I have a period

I do not have a period due to menopause

I do not have a period due to birth control

I do not have a period due to surgical intervention

I do not have a period due to a medical condition

I do not have a period because I am not a woman

Hormone Health Quiz* This field is required.Check all that apply and please feel free to elaborate in the "other" section

I have low or no libido

I struggle with depression, mood swings or cry easily

I have anxiety or panic attacks

I have no motivation

I am tired no matter how much I sleep

I am tired because I have trouble with my sleep

I am angry or on edge often

I have brain fog

Have you been diagnosed with any health conditions? If so, please list them below

Are you taking any prescription medications or supplements? If so, please list them below

Is there anything else you would like me to know about your internal, mental, gut or hormonal health? If so please elaborate below; if not skip ahead to the next section.

Are you currently following any nutrition plan? If so, please elaborate below.

How do you feel about cooking?* This field is required.Check all that apply and please feel free to elaborate in the "other" section

I love to cook

I don't mind cooking

I hate cooking

I have plenty of time to cook

I have time to cook most of my meals

I don't have time to cook most of my meals

How often do you dine out, order in, drive thru, starbucks, etc? Feel free to elaborate in the "other" section* This field is required.

Never

Once a week

2-3 times per week

3-5 times per week

Daily

More than once a day

Are you currently following any exercise program? If so, what are you doing and how often are you doing it?* This field is required.

Describe your experience with strength training.* This field is required.Check all that apply and please feel free to elaborate in the "other" section

I have no experience with strength training

I have done some strength training

I have strength trained in the past

I am currently following a strength training program

Where do you plan to work out?* This field is required.Check all that apply and please feel free to elaborate in the "other" section

At the gym

At home and I have a home gym

At home and I will purchase the recommended kit for about $100

I would like to options to work out at home or in the gym

Do you have any injuries or physical limitations?

Have you ever worked with a personal trainer?* This field is required.

YESNO

How important is it to you to reach your health and fitness goals.* This field is required.Check all that apply and please feel free to elaborate in the "other" section

100% so important, I'll do whatever it takes! Progress towards my goals is the most important thing!

90% pretty darn important but I'm not willing to get that uncomfortable. I am willing to make a lot of changes but

80% I am willing to make some changes but do not want to be uncomfortable

70% I want to take baby steps and stay as comfortable as possible

50% or less, not important I give no fucks about my health & fitness goals

Are you willing to prioritize your goals by making time in your schedule and budget?* This field is required.

YESNO

Select services and packages you are interested in* This field is required.Check all that apply and please feel free to elaborate in the "other" section

The basics and as affordable as possible- customized nutrition and exercise plan only

I would like to learn more about adding on 1:1 virtual personal training

I would like to learn more about mindset coaching with FWM certified counselor Celeste Rains-Turk

I would like Sarah to put together what she thinks is optimal for my goals

What is your desired start date?* This field is required.

Is there anything else you would like me to know before I create your customized coaching package? Don't be shy! :-)