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YMCA Wellness Coaching Interest Form
At the Y, we look forward to supporting you as you work toward your wellness goals! Please complete this form to request more information and a follow up call about our wellness coaching programs.
Please complete the following information to help us best meet your wellness needs:
Please select which program(s) you may be interested in:
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Coach Approach: The Coach Approach is an exercise support program designed help new and returning exercisers set goals, develop healthy habits, and stay on a consistent exercise program. Must be 18 years of age or older.
Weight Loss For Life: Weight Loss For Life adds the next level to our signature Coach Approach program, which has improved the physical activity, self-confidence and the emotional well-being of thousands of Y members. In tandem with Coach Approach, Weight Loss For Life, the next step is establishing wise, controlled eating habits, using behavioral tools that create long-term dietary change!
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Are you currently exercising 2-3 times per week?
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YES
NO
Have you been exercising 2-3 times per week for at least 6 months or longer?
*
YES
NO
Please select the best time(s) of day for a wellness coach to call to schedule your appointment:
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8:00 am - 12:00 pm
12:00 pm - 5:00 pm
5:00 pm - 7:00 pm
Please list any questions you have about the Coach Approach or Weight Loss for Life in the space below:
Thank you for your interest. Our wellness coaches will be in touch with you soon!
Submit
Should be Empty: