Coaching Application
Your Journey Starts Here
Name
First Name
Last Name
Email
example@example.com
Phone Number
-
Area Code
Phone Number
What is your current age?
What is your height ?
What is your current weight ?
What are your primary goals ?
Lose 20 lbs or LESS
Lose 20 lbs or MORE
Decrease Bodyfat
Improve Fitness
Get off Medications
Lose Belly fat
Tone Up
Improve my Health
Improve my self-image
Other
What do you need help with most?
Nutrition
Workouts
Time management
Accountability
Other
Any health concerns?
Diabetes
Blood Pressure
Cholesterol
Depression
Cancer
Joint Pain
Other
What has prevented you from achieving your goals ?
Guidance
Accountability
Support
Consistency
I quit on myself
I have hit a plateau
Procrastination
Poor food choices
Not enough exercise
Emotional / Stress Eating
Other
How much are you willing to invest right now?
$100
$150
$200
Other
On a scale from 1-5, how ready are you to make this change?
1
2
3
4
5
Are you willing to invest financially, emotionally, and with time and energy to accomplish your health & fitness goals?
Yes I Am Ready to Change My Life
No I will just stay stuck
Other
What do you feel is your biggest roadblock to achieving your goal?
Anything Else You Want Me to Know?
Save
Submit
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