New Client Intake Questionnaire

1
Full Name* This field is required.First and Last
First Name
Last Name
2
Email* This field is required.Preferred email
example@example.com
3
Phone Number* This field is required.
Please enter a valid phone number.
4
Mark the reasons that best describe why you could benefit from coaching.* This field is required.
Fat Loss
Weight Loss
Improving Posture and Form
Muscle Gain
Nutritional Guidance
Life and Habitual Guidance
Accountabilty
Improving Cardio and Conditioning
5
An average client that works with me loses 12lbs in the first 6 weeks and then they start to fill out their clothes how they want to. Are you okay with this?
Yes
Yes, but I would rather maintain my weight and turn it into muscle
That's insane but YES!
No
6
Describe your goal that would feel so amazing to achieve you couldn't help but to be incredibly proud.* This field is required.
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Ok
Ok
7
How long do you think this would take to accomplish on your own?* This field is required.
8
Do you want to sustain it after achieving it?* This field is required.
YESNO
9
How long have you wanted this?* This field is required.
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Large
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Small
Ok
Ok
10
Why is it important to you?* This field is required.
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Large
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Small
Ok
Ok
11
Why would you be a success?* This field is required.
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Large
Normal
Small
Ok
Ok
12
What days and time of day do you plan on working out?* This field is required.Ex. Monday, Wednesday, and Friday before work at 5:30a.m.
13
What is your current weight? What is your desired weight?* This field is required.
Current
Desired
14
Have you struggled in the past with eating well consistently?* This field is required.
YESNO
15
How would you define the way you deal with stress in your life?* This field is required.My person example: "I used to drink a lot. Now I pray and eat ice cream in silence." Both can improve right?
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Ok
Ok
16
Have you struggled in the past with working out consistently?* This field is required.
YESNO
17
Do you think if you had an expert showing you how to reach your goal, you would get there faster than on your own?* This field is required.
YESNO
18
If you had daily accountability helping you implement each step to hit your goal, do you think you'd be more likely to hit your dream down the road?* This field is required.
YESNO
19
I realize that my goal may take longer longer but permanent success is most important.* This field is required.This is about you.
AgreeDisagree
20
Please initial below as a statement that you agree to do each item below in exchange for reaching your goal?* This field is required.These include: Follow the nutrition, fitness, accountability, checkins, weekly plans, and recommendations we implement into your program.
21
Did any one refer you?If yes, type their name below. If no, put "n/a".
Should be Empty: