In Person Intake Form

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Congratulations on taking the first step towards becoming the best version of yourself! Please complete this application form and I will contact you promptly.
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Date of Birth*

MonthDayYear
Date
Gender pronouns*
Height*
Weight*
Emergency contact name & relationship*
Emergency contact phone number*
Please enter a valid phone number.
Please state what you do for a living and how active you are in that job.*
Please list the physical activity you do currently outside of work, how often and for how long*
Do you have any diagnosed health conditions?*
Do you have any injuries, physical limitations, or regular aches and pains?*
Are you currently taking any medication? Please list them.*
Are you undergoing any professional health services?*
Are you experiencing any stress or motivational problems?*
Has anyone in your immediate family developed heart disease before the age of 60?*
Have you had any chest pain in the last 30 days?

YesNo
Has a doctor ever told you that you should only perform physical activity as recommended by a doctor?

YesNo
Do you know of any reason why you should not participate in physical activity?*
Do you suffer from diabetes, asthma, high or low blood pressure?*
Are you a current cigarette smoker?*
Your current diet could be described as?*
Please explain in more detail if you wish
Are you pregnant or have you ever been pregnant?*

I am currently pregnantI have been pregnant beforeI am pregnant and have been beforeNo
Date that your last child was born*

MonthDayYear
Date
Select your top 3 goals from the following list*

Improved healthImproved enduranceIncreased strengthIncreased muscle massFat lossImprove core and pelvic floor functionFeel less stressed or anxiousHave fun
What is your specific goal with your training?*
Why?*
Are you willing to commit to 3 months of training?*
On a scale of 1-10 how motivated are you to reach your goal?*
How many sessions are you interested in/week?*
What are your expectations of me as a trainer?*
What days and times are you available to train?*
Do you feel there is anything else I need to know?*
How were you referred to me?

FacebookInstagramGoogleI was referred by someoneOther
If you answered "referred by someone" or "other". Please type their name or explain how you arrived here.
Would you give consent for me to sometimes take photos/videos for promotional purposes? (This would only be for bootcamp classes, not 1-on-1 sessions)*

YesNoI'm not doing bootcamps
Which service are you interested in?*

1-on-1 Sessions (I need a personalized plan, or prefer to work independently with a coach)Strong Mama ClassCOREset Method (Online Training)Not sure, lets chat :)
If you selected 1-on-1, which location would you like? (Leave blank if doing Classes)

3445 Luxton Road, Happy Valley Langford (Select this for classes and/or 1-on-1)2021 Haley Rae Place, Langford (Select this for 1-on-1 only)
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