New Year Intake Form

2026 New Years Plan

This is a limited and exclusive New Year’s deal for those ready to commit to a transformation. Have a fresh start on building back up your mental and physical health as we head into 2026
Client Name*

First NameLast Name
Age?*
Height?*
Current Weight?*
Phone Number*
IG Handle*
How do you feel about your current mental health and mindset? What areas do you struggle with most?*
What are your 2 habits you know are detrimental to you and your 2 habits that you want to build to improve your well-being?*
What are your top 3 mental goals for 2026? (e.g., improved focus, reduced stress, building confidence, emotional balance, etc)*
What are your top 3 physical goals for 2026? (e.g., strength, weight loss, endurance, mobility, aesthetics, muscle gain, etc.)*
If you could sit down with your future self at the end of 2026, what would you want them to say about the person you became and the work you put in?*
Please state if you have any current/previous injuries/health diseases/issues.*
Please state whether you take any medication.*

What is your rate for your nutrition?*

	0	1	2	3	4	5

0 is Poor, 5 is Excellent

How serious are you on becoming better in 2025?*

	0	1	2	3	4	5

0 is Poor, 5 is Excellent