Coach Tanya Kingsbury New Client Form

Full Name*

First NameLast Name

Phone Number*

E-mail*

example@example.com

How much do you think you weigh?*

It is ok if you don't know. Just your best guess.

How tall are you?*

It is ok if you don't know. Just your best guess.

Are you taking any medications?*

How many meals do you currently eat per day?

Are you...*

PregnantNursingPre MenopausePost Menopause

Do you exercise?*

Rate the quality of your sleep*

How many pounds away are you from feeling confident?*

How many other weight loss programs have you tried? I had been literally been on diets since I was 10 years old... I get it!*

Right now, how would you describe your overall health? Physical, mental, energy, self confidence..*

What would your dream health/weight goals look like?*

What would you change about your life right now to make it better? I get some deep responses here and I want you to know this is totally confidential. My drinking was causing many of the issues with my family and my life. I understand so please share away...*

Why do you want to lose weight? What do you think will be different in your life when you get to a healthy weight (which you absolutely can)!*

On a scale of 1-10, how committed are you to getting to your health goals?*

Is there anything you can see that would stand in the way of you achieving your health goals?*

I am 100% confident in the program and its ability to work for everyone. Literally, you are the only variable to the programs success. Its simple, not always easy, but the things that matter in life are never easy. I know you can lose the weight you want with my help, but with you being the only variable, if you fail, its your fault, if you succeed its also your fault. How does that make you feel? Scared? Good! I was too. BUT, my life was in shambles because of all the things I could NOT control. I decided to be excited that I could control one part of my life. How do you feel now? I am so excited to work with you!*

TANYA KINGSBURY HEALTH STARTING POINT