Nutritional Coaching Form

Nutritional Coaching Form
Client Details:
Full Name*

First NameLast Name
Phone Number*
E-mail*
example@example.com
Preferred Method of Contact?*
Did Someone Refer You? If so, who?
Current Age*
Height*
Current Weight*
Which coaching option are you interested in?*

1x Consultation Only $150In Person Or Virtual Consultation + 3 Months Additional Coaching ($250 for consult +1st month then $100/Month for 2 months)In Person or Virtual Consultation + 6 Months Additional Coaching ($235 for consult +1st month then $85/Month for 5 months)In Person or Virtual Consultation + 12 Months Additional Coaching ($220 for consult + 1st month then $70/Month for 11 months)
Which type of initial consultation (60 minute appt) would you prefer?*

In person (481 N Perry St. Ottawa, OH)Virtual
Please list days & time frames that would work best for setting up the initial consultation. Weekend availability is limited but may be an option at times. If you would prefer to book your own appointment, you can do so online at buildingresiliencept.janeapp.com*
Preferred payment method*

Credit / Debit CardVenmo @Jenna-MaagCash (local clients only)CheckPayPal (JmaagPT@gmail.com)
If you plan on becoming a monthly coaching client.....Do you agree to communicate with me EACH week for check-in's (via email, text or phone calls) and be open / honest about how things are going for you? I will NOT hunt you down each week and force you to respond. It is YOUR responsibility just as much as it is mine to keep an open line of communication.*

YesNo (please do not waste your time filling out the rest of this form)
What is your occupation? Do you have any hobbies that you enjoy?*
How active are you throughout the day?*

Sitting most of the dayCombination of standing, sitting, and walking aroundOn my feet most of the dayI have a physical job that requires a lot of lifting, pushing, pulling etc
How many steps do you average per day?*

<50005000-80008000-10,00010,000-12,00012,000-15,00015,000+
Anything in your medical history I should be aware of?*
What are your biggest health and/or fitness GOALS that you would like to achieve? Do you have a timeline for these goals?*
WHY are those goals important to you?*
If weight loss is a goal, approximately how much weight do you think you'd like to eventually lose? *
Ideally, how would you like to FEEL in the future (6 to 12 months from now)?*
What are you most interested in learning about regarding nutrition, fitness, living a healthier lifestyle etc?*
What are your expectations for me as your coach? *
What have you tried in the past? What has worked well for you? What has NOT worked well? *
What do you find to be the most DIFFICULT things for you when it comes to nutrition and exercise?*
How often do you currently exercise, if applicable? (# of days and amount of time on average)*
How often do you currently exercise, if applicable? (# of days and amount of time on average)*
What do you typically do for exercise? *
Rate your current stress levels on a scale of 0 to 10. (0= NO stress, 10 = EXTREME stress)*
How many hours of sleep do you average per night? *
What are you willing to do / change?*
What are you NOT willing to do / change?*
How many meals / snacks do you eat per day? *
What and approximately how much do you typically DRINK in a day? (water, coffee, regular soda, diet soda, tea, alcohol etc)*
How often do you drink alcohol & how much do you typically drink when you consume alcohol?*
What is a typical day like for you (routine/ schedule/ lifestyle)?*
What do you typically eat in a day? BreakfastLunchDinnerSnacks*
Favorite foods?*
LEAST favorite foods / intolerances or sensitivities?*
LEAST favorite foods / intolerances or sensitivities?*
Describe how your support system is regarding health, fitness, and nutrition? Do you have family members or friends who are on a similar journey or who would at least be supportive of you making healthier choices? *
Anything else you think I should know about you? *
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