New Client Application

Name* This field is required.

First Name

Last Name

Email* This field is required.

example@example.com

Phone Number(For Discovery Call)

Area Code

Phone Number

Primary Goal(s)Check All That Apply

Heal Relationship w/ Food

Build Muscle

Lifestyle & Habit Changes

Lose Fat

Gain Weight

Improve Athletic Performance

Improve Mental Clarity

Live a Normal Life

Describe your current relationship with food, your body and exercise. What does it look like now and how would you like to see it change?Please also indicate if you've struggled with an eating disorder, emotional eating, or binge eating.

What meal plans, diets or exercise programs have you done in the past or are currently doing? What HAS worked for you, and what has absolutely NOT worked for you?Be as detailed as possible!

Give me an an example of what a typical full day of eating looks like for you. (The good, bad and ugly! Just be honest)Be as honest & detailed as possible! No shame or judgement here!

Do you have any health conditions or injuries? (PCOS, Diabetes, Hypothyroidism, IBS, Insulin Resistance, etc.)

Any food allergies?

What Medications and Supplements are you currently taking?

Do you have a history with any eating disorders?Please Explain.

Anything else about your health history I should know?

Have you ever Tracked Macros in the Past?

YESNO

Have you ever tracked calories?

YESNO

Top 5 Favorite things to eat.

What foods to you totally dislike?

What would you say your health and wellness goals are for the next 3-6 months, and why are these important to you? Be as specific and detailed as possible!

What would you say is your biggest obstacle to achieving your nutrition goals?

What do you feel you need to help reach your goal and/or heal your relationship to food? Can be ANYTHING

How ready do you feel about committing to your health and fitness goals?

How much has your weight changed in the past 12 months?

How many hours a day do you sit?

How many steps do you get? If unsure, write "unsure."

How many days a week do you workout? Describe your workouts.Strength?-days and hours Cardio- type/ days/ hours

Is your digestion regular/irregular? Experiencing any persistent abnormal bloating, constipation, GI discomfort?

If Applicable: Are your hormonal cycles regular?

How many hours of sleep do you get?

Rate the quality of your sleep

Rate your daily energy levels

Rate your Stress Levels

List 3 things that bring you pleasure & joy.

List 3 ways (good or bad) you do to cope with stress.

How much water do you drink each day?

What goals do you want to achieve from this program over the next 4-6 weeks (Health, Fitness, Nutrition, Body Image and Stress Reduction)?

What would having the perfect relationship to food look like to you? What would it enable you to do? What kind of person would you be?

What are you prepared to do to hit your goals?

What concerns or hesitations do you have about taking this next step in your health journey?

Anything else you want to add?