Functional Health Coaching

Apply for 1:1 Coaching with Mitch

This journey is for those who are ready to do the deeper work to heal - not just looking for a quick fix. For this reason, I require a minimum 12-week commitment to ensure meaningful and sustainable results.
Name*

First NameLast Name
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
What do you do for work? Is it physical or sedentary?*
Gender*

MaleFemale
Date of Birth*

MonthDayYear
Date
Age*
Height (in CM)*
Weight (in KG)*
Instagram handle*
What goals are you hoping to reach with my support?*
E.g. gut/hormone health, build muscle/or drop body fat, comp prep...
What is your current diet like? - Please be specific - what foods are you currently eating, how many meals per day etc*
What are your current calories? *
Do you have any food intolerances/allergies?*
Do you have any medical conditions? Please be specific - e.g. Diabetes, Crohns, PCOS, Autoimmune etc*
If you are on any medications, please list them.
Please list the foods that you dislike*
What is your sleep like? How many hours per night?*
Do you have children? If so, how many?*
How is your libido like?*

LowAverageHigh
What supplements/vitamins do you currently take?*
How are your stress levels?*

LowModerateChronic
Are you on any drug enhancements/ or have you taken any before? *
What do you do for exercise? (Please include how many days per week)*
This can include: Weight training, walking, yoga, etc
What time of the day do you train?*
Do you have any injuries or limitations?*
Gut health: Do you suffer from any of the following?*

Reflux/heartburnBloating/abdominal discomfortConstipationDiarrheaIBD (Crohn’s Disease, UC)IBSCeliac DiseaseSIBONauseaCandida overgrowthDiverticulitisNone of theseOther
Lifestyle + Mental: Do you regularly experience any of the following?*

Stress/AnxietyLow self-confidenceNegative self-talkLimiting thoughts/beliefsSelf-sabotagingDepressionPoor relationship with foodNone of theseOther
Do you wake up frequently through the night to pee? *
Do you experience hot flushes or night sweats?*
Do you feel dizzy when exercising?*
Do you experience energy crashes throughout the days? If so, what time of the day roughly?*
FEMALE ONLY: Do you get a regular cycle?
Does it arrive on time? Do you experience heavy or bleeding.. etc
FEMALE ONLY - When is your cycle due?
FEMALE ONLY: Are you on birth control?
FEMALE ONLY: Do you experience sore breasts or aches around your cycle?
FEMALE ONLY: Do you experience stomach pains during ovulation (the lead up) and during your period?*
Do you experience pain on one side of the stomach? If so, which side?
Anything else you would like me to know about your health/lifestyle?*
Are you ready to commit to a minimum 12-week+ coaching program, starting from an investment of $1,020 (AUD), to address the root cause of your health concerns and achieve long-term results?

Yes, I’m ready to commit!Not at this time
When are you looking to take action on your health goals?

As soon as possible!Sometime in the near future. I'm not quite ready yet.
How would you like to be contacted?*

EmailInstagram
Please allow 24hours for a response. If you are wanting an email response, please keep an eye out in your spam/junk mail aswell.
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Apply for 1:1 Coaching with Mitch

Please allow 24hours for a response. If you are wanting an email response, please keep an eye out in your spam/junk mail aswell.