Client Intake Form

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Client Name* This field is required.
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Preferred email address?* This field is required.
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Preferred contact phone number?* This field is required.
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Do you have any health conditions/concerns or physical limitations that impact your ability to exercise ?* This field is required.
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Recall a time you felt the most healthy and fit in your life. When was that? What were you doing then?* This field is required.
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Aerobic Physical Activity: How often do you do moderate-intensity to vigorous intensity physical activity (like brisk walking, jogging, biking, hiking etc.) per week? and How many minutes do you do on these days?* This field is required.
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Resistance training: Currently, how many days per week are you resistance training? (lifting weights, using resistance bands etc.) How many minutes do you do on these days?* This field is required.
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What are some of your favorite exercises?* This field is required.
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What would you say is your number 1 health/fitness goal?* This field is required.
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What are your TOP 3 goals you want to achieve while working together?* This field is required.
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How CONFIDENT are you in achieving this goal? On a scale of 1 - 10. [1 being not confident, 10 being I 100% confident ]* This field is required.
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Please Select
1 - Not feeling that confident
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5 - Feeling condifdent but also unsure
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10 - I'm feeling 100% confident that I will work on what I need to for me to achieve my goals!
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How important is this change for you? On a scale of 1 - 10. [1 being not very important, 10 being this is a top priority for me]* This field is required.
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Please Select
1 - Not that important
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5 - It's important but NOT a top priority
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10 - This is a priority and I need to make this change for me.
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How long have you been working towards this goal?* This field is required.
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Please Select
1 - I'm just thinking about getting started
2 - Less than 3 months
3 - Less than 6 months
4 - 1 year +
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If you've already started working towards your goal, what was it that got you started?* This field is required.
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What have you already tried in terms of achieving your goal? (Ex. any other programs or coaches/trainers you’ve worked with/tried?) What do you think got in the way?* This field is required.
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Do you feel like you have a hard time figuring out How/what to EAT to reach your health/fitness goals? (A.K.A Nutrition seems confusing! :/ )* This field is required.
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Is there anything you’re currently doing that you feel IS helping you get closer to your goal? (have you maybe made some routine changes, started walking more, working on eating more nutritious food options etc.)* This field is required.
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Let's fast forward and imagine you've reached the point where you've achieved your fitness and health goals. Where do you see yourself at 1 year? and where do you see yourself in 5 years ? How do you think you'll feel?* This field is required.
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Are you comfortable being weighed on the scale?
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No
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Are you comfortable with body measurements?
Yes
No
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Are you comfortable with progress photos? (photos are never shared without your written consent)
Yes
No
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How would you like me to support you if you find yourself falling behind on your tasks or your own expectations?
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Is there anything else you’d like me to know about you as it relates to working together?
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SignatureAwesome, done! Thanks so much for filling out your intake form! . I'm so excited to be working with you and can't wait to see all the amazing WINS you're going to achieve! I'll be in touch shortly :)
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