LET'S TALK GOALS DISCOVERY FORM
I’m so glad you’re here! This quick form will help me learn more about where you are in your health journey and what kind of support you need. There’s no pressure — just a caring space to get clear on how I can best help you.
Name
*
First Name
Last Name
Email
*
example@example.com
Today's Date
 -
Month
 -
Day
Year
Date
Best number to reach you on
*
Please enter a valid phone number.
Format: (000) 000-0000.
How did you hear about me, or my programs?
If you were referred, please list the name of the person who referred you so I make sure I give them their referral bonus! :)
Awaken.
..
Discover where you are and where you want to be!
What are your top health or weight-related goals right now?(Examples: Lose weight, gain energy, reduce inflammation, get consistent with healthy habits)
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What has made reaching those goals feel hard up to this point?
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Please describe WHY you are interested in making changes to your health. ( What is your main motivation.. How you feel, activities, relationships, etc)
*
Check any that apply to you and your goals
Lose Weight
Gain Weight
Gain Muscle
Increase Energy
Take Fitness Goals To Next Level
Learn Healthier Eating Habits
Have More Confidence
Healthy Mindset
Possibly Reduce Or Come Off Medications
Other __________________________
Medical
We can discuss some medical considerations or prescriptions when we chat
** The program I coach is a habit transformations system that addresses lifestyle change in the form of nutritional support. We also offer combination therapy options for those seeking medically supported weight loss, along with our nutritional programs. Do you desire to discuss if this could be an option for you?
Current Lifestyle & Habits
How would you describe your current eating habits?
Pretty balanced most days
All over the place — no real structure
try to eat clean but I struggle with consistency
I skip meals and snack later
Other
If you selected "Other" Be explain
How many meals do you typically eat in a day?
1-2
3
4-5
6 or more
It varies day to day
How many days a week do you eat out or grab food on the go? (coffee runs, fast food, sit down restaurants, take out, vending machines, etc)
Do you ever struggle with emotional eating, cravings, or late-night snacking?
YES
NO
SOMETIMES
How much water do you drink each day? (Rough estimate is fine - Example 40oz, 1 gallon, not sure, etc)
How often are you physically active (even just walking)?
Daily
A few times per week
Rarely
What physical / exercise activities do you participate in? *We have specific programs for people who are active and other ones for people who do not have time to or do not wish to workout.*
What do you do for living?
Are there other stressors in your life?
Do you have healthy, active friends & supportive family?
Is there anyone in your life who would like to get healthy with you? I have seen great success for those folks who join with a friend or partner. I also offer a discount if you sign up with a friend! ;)
What would your dream health/weight/activity goals look like?
*
Is there anything else you'd like to share with me before we connect?
On a scale of 1 to 10, how ready are you to make changes to improve your health?
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Just Thinking About It
1
2
3
4
5
6
7
8
9
Ready For Change!!!
10
1 is Just Thinking About It, 10 is Ready For Change!!!
Submit
💬 Thank you! I’ll be reviewing your answers and reaching out shortly to explore how I can best support you on your journey.
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