Let's talk about your health goals
Hi! My name is Marie Stivene. I'm a Certified Personal Trainer, Certified Nutrition Coach, and Certified Group Exercise Instructor. As a pastor's wife and mom of 3, I'm passionate about helping women build healthy habits, nourish their bodies, and become stronger physically, mentally, and spiritually.I created this short survey to get to know you better: your goals, your challenges, and where you need the most support. Your answers will help me determine how I can best support you on your health journey.Whether you're looking to lose weight, build healthy habits, gain energy, or become more consistent, I'd love to learn more about you.Thank you for taking a few minutes to complete this survey. Your responses are completely confidential, and I truly appreciate your time. ❤️
What's your full name?
First Name
Last Name
What's your email address?
What's your phone number?
Please enter a valid phone number.
Format: (000) 000-0000.
What's your Instagram or Facebook name?
How old are you?
Under 25
25-34
45-54
55+
What is your biggest health goal right now?
Lose weight
Build healthy habits
Tone up
Gain energy
Improve my nutrition
Feel more confident
Other
What is your biggest struggle when it comes to your health?
Staying consistent
Emotional eating
Lack of time
Knowing what to eat
Lack of motivation
Exercising regularly
Other
On a scale of 1–10, how committed are you to reaching your health goals?
Have you tried to lose weight or get healthier before?
Yes
No
What has stopped you from succeeding in the past?
How would you rate your current digestive health?
Poor
Fair
Good
Excellent
Do you skip any meals?
Breakfast
Lunch
Dinner
I'm a snacker
I don't skip meal
What is your current eating habits like? (including fast foods)
*
Feel free to elaborate. Include any food allergies or dietary restrictions.
How much do you spend on food per week?
150$
250$
300$+
Would you like support and accountability from a coach?
What's your fitness activity level?
5+ x per week
3-4 x per week
1 - 2 x week
Not at all but I want to start working out
Have you ever taken or are you taking supplements?
Yes
No
Are you in a place to invest in your budget for fitness and nutrition programs/coaching services?
Yes
Not at the moment
If we worked together, what would success look like for you in the next 3–6 months?
Is there anything else you'd like me to know about your health journey?
Thank you
Thank you for completing this survey! I'll personally reach out to you.
Submit
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