Free Consult Registration Form

FREE CONSULTATION

REGISTRATION FORM
When you answer the questions below, we will learn more about your lifestyle habits and goals. This will allow us to provide you with the best personalized, custom tailored service possible! Some questions may overlap a tiny bit but that is because we really do try to get the big picture AND dive deep into the details where possible!
If you are stuck on anything, just answer to the best of your ability! Our staff can go over it with you in greater detail during your FREE Consultation Session!

Questions with a * are required in order to proceed.
Technology
HQ Health Coach heavily relies on technology, websites, apps and online tools to communicate with clients and deliver personalized coaching services.

Are you ready, willing and able to receive coaching through online platforms and learn how to interact/use these technologies?

(We will teach you how to use each app and online tool if you are not familiar with them!)
I AM VERY TECH-SAVVY. I am ready, willing and able to use these apps and online tools.I AM SOMEWHAT TECH-SAVVY. I am ready, willing and able to learn and use these apps and online tools.I AM NOT TECH-SAVVY but will be fine with some help. Although I will need more support, I am ready, willing and able to learn and use these apps and online tools.I HAVE NO INTEREST in using web-based technologies, apps and online tools to receive coaching.

Personal Info
Email*
example@example.com
Cell Phone Number*
(Optional)
Secondary Phone Number
(Optional)
When is the best time to reach you by phone?
Name*

First NameLast Name
Date of Birth

MonthDayYear
Date
Biological Sex*
Gender Identity
Preferred Pronouns

She/HerHe/HimThey/ThemOther
City of Residence*
Current Province / State*
Country*
Ethnic Background*
Language(s) Spoken*
What electronic devices do you own and have available for you to use for coaching sessions? Check all that apply:*

SmartphoneDesktopLaptopiPad / TabletNone of the aboveOther
Transportation & Mobility. Select all that apply:*

I own/have access to a carI do not own/have access to a carI mostly drive myself to wherever I need to goSomeone else usually drives me around when I need to go anywhereI usually commute via public transport (bus, train, etc)I always uber or take a taxiI usually bike, skate, etc to get aroundI normally get around to most places by walkingOther
Medical History
Do you have a Family Doctor?*

YesNo
What other Healthcare Professionals and Specialists are involved in your care:
Current / Ongoing medical conditions:
Previous/resolved medical conditions:
Surgeries/Procedures or Hospitalizations:
Allergies:*
Paternal Family Medical History:
Maternal Family Medical History:
Are you on hormone-replacement or hormonal birth control?*

YesNo
Prescription Medication:*
Over-the-counter Medications:*
Herbal Products:*
Vitamins or Mineral Supplements:*
Smoking History:*

Never smokedUsed to smoke but quitCurrently still smoking
Alcohol History:*

Never drank alcoholUsed to drink alcohol but quitCurrently still drink alcohol
Coffee/Caffeinated Drinks:*

I drink coffee or caffeinated drinks every dayI occasionally drink coffee or caffeinated beveragesI avoid coffee or caffeinated drinks
Do you take any recreational substances?*

YesNo
Priorities & Expectations
Priorities for Coaching

Leave a checkmark beside a goal/issue you want to address with your potential coach.

	This is a goal/issue I want to address
Improve Overall Well-being
Improve Family Well-being
Improve Energy
Improve Productivity
Be More Organized
Have A Tidier Living Space
Improve Work/Life Balance
Improve Finances
Improve Cognitive Function
Improve Sleep
Manage Stress Better Or Reduce Stress
Improve Personal Relationships
Develop Or Improve Social Skills
Find Fulfillment In Life
Be More Spiritual
Be Happier
Feel Better

	This is a goal/issue I want to address
Look Better
Lose Weight/Fat
Gain Weight
Maintain Weight
Build Muscle
Improve Physical Fitness
Get Stronger
Have More Energy And Vitality
Get Control Of Eating Habits
Improve Health Risks Or Medical Conditions
Reduce Need For Medications

	This is a goal/issue I want to address
Recover From An Illness Or Injury
Resolve Mood Disorders
Battle An Addiction
Manage Drug Or Alcohol Issues
Quit Substance Use (Alcohol, Smoking, Etc)
Physique Competition / Modeling
Improve Athletic Performance
Explore My LGBTQ+ Identity

Please note that certain health & wellness related goals of yours may fall outside the scope of knowledge and skill of HQ Health Coach and its coaches. In these cases, we reserve the right to decline coaching and may recommend other avenues or resources to turn to for you to address your concerns.
Please list any other concern(s) about your health, eating habits, fitness and/or body:
What else are you worried about? What frustrates you?
Out of all of the above concerns, Which ones feel most important / urgent?
HOW would you like your habits, your health, your eating, and / or your body to be different? What is your vision?*
What obstacles are getting in the way of achieving your vision?*
IN THE PAST, what changes or strategies to improve your health worked well for you? *
(Even if you might not be doing it right now.)
IN THE PAST, what health strategies DIDN'T work well for you?
How Our Sessions Are Conducted
Typically, a session is conducted every week and can be delivered via either a Live Session (phone or video call) or a Video Session depending on the program the client signs up for.

In our sessions, we cover topics related to biology, mindset and behaviour change. Including but not limited to: what your body needs to be healthy, how your nutrition affects your health, how your environment affects your health...etc.

Along with educational topics, our coaches provide clients with actionable steps and tasks they can complete to establish healthy habits and routines for long-lasting change and transformation.
ON A SCALE OF 1 - 5 : How READY are you to learn new information and gain knowledge from your sessions?*

1

2

3

4

5

1 is Not at all, 5 is Completely
How WILLING are you to learn new information and gain knowledge from your sessions?*

1

2

3

4

5

1 is Not at all, 5 is Completely
How ABLE are you to learn new information and gain knowledge from your sessions? *

1

2

3

4

5

1 is Not at all, 5 is Completely
Below are some behaviours, habits, tasks and activities that a coach could POTENTIALLY ask you to work on/improve:

- Eliminating certain foods and drinks

- Adding new foods including vegetables, healthy fats, fruits, fibre-rich carbs and proteins to your meals

- Drinking up to a certain amount of water daily

- Tracking your nutrition and activities

- Changing your morning and bedtime routines

- Sleeping at different times than you are used to

- Organizing and rearranging your daily schedule and routine

- Completing short assessments and forms on an ongoing basis

- Using online apps and tools to track, organize and analyze your progress

~ But It Really All Depends On Your Goals ~
Our coaches also check-in with their clients to discuss their progress and any obstacles they may be facing with the new task or habit assigned to them.

It is a key part of coaching to share with the coach about your progress and any feedback about the changes/tasks that you have been coached about.

---

You may be asked to do tasks that are new to you.

They may be challenging... and consistency will be important.

The strategies that will get you the RESULTS you want may require you to make changes to your current lifestyle, behaviour and habits.

---

~ Your Coach Will Guide & Support You Every Step of the Way ~
ON A SCALE OF 1 - 5 : How READY are you to change your behaviors, habits and current lifestyle in order to achieve your health and wellness goals?*

1

2

3

4

5

1 is Not at all, 5 is Completely
How WILLING are you to change your behaviors, habits and current lifestyle in order to achieve your goals?*

1

2

3

4

5

1 is Not at all, 5 is Completely
How ABLE are you to change your behaviors, habits and current lifestyle in order to achieve your goals?*

1

2

3

4

5

1 is Not at all, 5 is Completely
How to Attend Your Free Consultation Session
Once you submit this form, a member of our staff will contact you to schedule your FREE session.

This session will take place via ZOOM

but will strictly be VOICE / AUDIO call only.

Your coach may share their screen for presentation purposes.
Disclaimer:

Please recognize that it is your responsibility to work directly with your primary health care provider before, during, and after seeking nutrition and/or fitness consultation. Any information provided by HQ Health Coach is not to be followed without prior approval of your doctor. If you choose to use this information without such approval, you agree to accept full responsibility and liability for your decisions.
Please read carefully and checkmark each box to acknowledge the statements below:*

I give consent to HQ Health Coach to collect and store my personal information and my personal health information for the purposes of discussion during our Free Consultation Session.I understand this form along with the Free Consultation Session will be used to determine whether or not HQ Health Coach is the right fit for my needs.I understand that the completion of this form and participating in the Free Consultation Session does not guarantee that I will be accepted as a client by HQ Health Coach.I understand that certain health related goals of mine may fall outside the scope of knowledge and skill of HQ Health Coach and its coaches. In these cases, HQ Health Coach reserves the right to deny my registration as a client, and may recommend other avenues.I UNDERSTAND THAT THE COACHING I AM EXPECTING TO RECEIVE IS NOT A SUBSTITUTE FOR MEDICAL OR PSYCHOLOGICAL CARE.
Full Name*
By entering your name here, you are acknowledging that you have read and agree to the statements and disclaimers presented above.
Today's Date

YearMonthDay
CAN THE FORM BE REVIEWED AFTER SUBMITTING IT?
To protect your privacy, form entries will not be sent to your email inbox for review.

CAN THE FORM BE DELETED AFTER SUBMITTING IT?
You may opt out of filling the form at any time prior to submitting. However, once you hit the submit button, your completed registration form cannot be retrieved or deleted by you and you must contact info@hqhealthcoach.com to have your submission manually deleted.

We are sorry that we could not meet your needs!
Thank you for your interest in receiving health and wellness coaching

by HQ Health Coach and its staff.

You have indicated that “you have no interest in using web-based technologies, apps and online tools to receive coaching” and that is 100% okay!

Some people like yourself may prefer

an in-person or face to face interaction.

Or you may prefer coaching over the phone only.

Unfortunately, HQ Health Coach does require that our clients are willing and able to use technology as that is the only way our team can deliver coaching and administrative services.

HQ Health Coach does not offer in-person or phone-only services at this time.

We understand that this way of coaching may not be suitable or the right fit for everyone and so, we do hope that you keep searching and find a coach or program that is best for your needs! Whether you choose to continue with HQ Health Coach or another coach/program, we hope that you do try to get the guidance and support you need!!

WHY DOES HQ HEALTH COACH USE TECHNOLOGY FOR HEALTH COACHING?

By using the apps and online tools that we do, we are able to deliver a coaching service that is far more in-depth and individualized to each person. The advantages far outweigh the minor drawbacks. The information we collect and the interactions that our clients have with the technologies we use, gives us a far better insight into a client's health, habits and lifestyles. This allows us to really custom tailor each coaching experience and focus our efforts on the right problem areas.

If you would like to go back and select a different option to proceed with booking a Free Consultation Session, please click the “Back” button below.
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FREE CONSULTATION

Technology

Personal Info

Medical History

Priorities & Expectations

How Our Sessions Are Conducted

How to Attend Your Free Consultation Session