New Client Consultation Form
Please fill in all the details and I will text you to set up a consultation date and time!
Full Name
*
First Name
Last Name
Gender
Male
Female
Non-Binary
Other
Age
years
Height
ft
Weight
If unknown that's okay
Phone Number
-
Area Code
Phone Number
Email
What do you do for a living?
What's the activity level at your job or otherwise overall lifestyle?
none(seated only)
Moderate (light activity such as walking)
High (heavy labor, very active)
Do you follow a regular working schedule, do you work days, afternoon or nights?
Please list the physical activities that you participate in outside of the gym and outside of work.:
If you have any diagnosed health problems list the condition(s).
If you are on any medications, please list them.
If you have any injuries, please list them.
Are you experiencing any stresses or motivational problems?
Yes
No
Are you experiencing any sleep issues?
Yes
No
Do you suffer from diabetes, asthma, high or low blood pressure?
Yes
No
if yes to any of the above, please list more details:
Are you a current cigarette smoker?
Yes
No
Please rate your readiness for change.
1
2
3
4
5
6
7
8
9
10
What following goals does best fit in with your goals?
Improved Health/Overall Wellness
Tone Up/Body Comp Change
Improve Energy
Increased Strength
Increased Muscle Mass
Fat Loss
Weight Gain
Build Confidence
Balance Hormone
Reduce Stress/Lower Cortisol
Build Healthy Habits
Improve Mood/Mental Clarity
Better Digestion/Gut Health
What is your biggest goal? What is your biggest struggle in achieving that goal?
Why?
TImeline for achieving your goal.
Rows
8 WKS
16 WKS
24 WKS
32 WKS
40 WKS
1 YEAR
NOW
Are you currently excersising?
Yes
No
Have you worked with a personal trainer or wellness coach before?
Yes
No
What type of coaching support do you feel you need most?
A structured wellness plan
Accountability & Motivation
Hormone Health/Lifestyle Coaching
A customized approach tailored to my needs
A sustainable and all-inclusive approach to wellness
Other
What are any expectations you have with working alongside a Wellness Coach? Why do you want to work with me?
At what times during the day do you have availability?
Morning
Mid-Day
Afternoon
Evening
Thank You!
I will be reaching out to setup your account and calendar booking request for consultation.
Submit
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