New Client Intake Form
Thank you for your interest in working with me! I can't wait to get to know you and help you become the best version of you! *Please note, all information is held confident. At no given point is information disclosed or shared without client’s written consent.*
Contact Information
Full Name
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First Name
Last Name
Age
What is your gender?
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Male
Femal
Non-binary
Prefer not to answer
Cell Phone Number
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E-mail
*
example@example.com
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Health Information
What is your current weight?
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What is your height?
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How would you classify yourself? Select all that apply.
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A busy proffessional
New mom
Stay at home parent
Student
Part-time worker
Other
What are your health goals?
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Lose weight
Build muscle and shed fat
Improve body composition
Gain weight/muscle
What areas of health and fitness are you wanting help with? Select all that apply.
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Improve nutrition
Build healthy habits
Workouts/Fitness
Mindset
Accountability
All of the above
Other
What, if any, are some things you've tried in the past to reach your goals that either didn't work or give you lasting results?
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What are some of the challenges you are facing that is preventing you from achieving your goals? Select all the apply.
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Lack of knowledge
Time
Work
Family/Friends
Medical condition/ Injury
Lack of support/accountability
Finances
Inability to commit to a structured program
Give up too easily
Other
Do you have a timeline for when you want to reach your goals?
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How determined and committed are you to reaching your goals?
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100000% COMMITTED!
75-100%
50-75%
Don't really care...
If my program sounds like a good fit for you, how much are you willing to spend monthly to achieve your goals?
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Money's not an issue
$500+
$300
Less than $100
Appointment
Select a date/time for our consultation!
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Submit
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