Application for Premier Cancer Coaching Tactics
Please fill out this form to apply for my specialized coaching program.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Best time to contact
morning
afternoon
evening
Other
Time zone
Preferred communication
email
phone
video call
Other
Person with cancer challenges (self, family member and relationship, friend)
Date of Birth
City, State, Country
Primary language
How did you hear about me?
referral
website
social media
Other
What are your main health concerns?
Primary cancer diagnosis (type; stage; date of diagnosis)
Current treatment status
planning
active treatment
post-treatment surveillance
recurrence management
Other
Current or planned treatments
surgery
chemotherapy
radiation
immunotherapy
hormonal
targeted therapy
Other
Please share your goals and expectations from the program.
Treating oncologist/center (name; institution; city)
Primary oncology contact permission (I consent to contact my oncology team if needed)
yes
no
Key medical documents available - select which you can upload after acceptance.
recent pathology report
treatment summary
active medication list
labs/imaging
genetic testing
Medications, Repurposed Medications, Supplements, and OTC Products
Current medications (name; dose; frequency)
Current repurposed medications (name; dose; frequency)
Current supplements and OTC (over-the-counter products) (name; dose; frequency)
Allergies and adverse reactions (drug; supplement; food; and reaction)
Goals and Priorities
Primary goal for coaching
enhance treatment effectiveness
reduce side effects
manage symptoms
prevent recurrence
optimize resilience
Other
Top 3 priorities or concerns
What would success look like at 3 months
What would success look like at 12 months
Lifestyle and baseline measures
Sleep (hours/night)
Activity level
sedentary
light
moderate
vigorous
Dietary patter
omnivore
plant-forward
vegetarian
vegan
carnivore
Other
Tobacco smoking/chewing/vaping status
current
former
never
Alcohol use
none
occasional
moderate
daily
Height and weight
Practicals and availability
Preferred coaching cadence
daily
weekly
every 2 weeks
monthly
Preferred session length
30 minutes
45 minutes
60 minutes
Time constraints or scheduling notes
Readiness and Commitment
Readiness to implement personalized protocols
not ready
somewhat ready
fully ready
Ability to follow nutrition, supplement, or lifestyle changes
limited
moderate
high
Barriers I should know about
transportation
caregiver responsibilities
financial
Other
Payment and program selection
Program interest
Premier Monthly Concierge
3-month intensive
custom plan
Other
Billing preference
monthly
upfront 3-month (discounted)
Accepted payment methods
credit card
debit card
Agreement to program fees and limited-spot policy (I understand spots are limited and fees are refundable as stated)
Please Select
Yes
No
Consent and Acknowledgement
Informed consent statement: I understand coaching is educational and supportive, not a medical diagnosis or emergency care; I will continue working with my clinical care team; I consent to share relevant records with my coach if needed.
Please Select
agree
disagree
Telehealth consent: I consent to video or phone coaching sessions and acknowledge the privacy limitations of remote communication.
Please Select
agree
disagree
Privacy and data use: I acknowledge the privacy policy and how my info will be used for coaching and scheduling.
Please Select
agree
disagree
Emergency and support contacts
Emergency contact name
Relationship
Phone
Primary caregiver name and availability (if applicable)
Optional attachments and final questions
Optional attachments you feel I need to consider.
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Anything else I should know?
Times that are typically best for coaching sessions
Monday mornings
Monday afternoons
Tuesday mornings
Tuesday afternoons
Wednesday mornings
Wednesday afternoons
Thursday mornings
Thursday afternoons
How soon would you like to start?
immediately
withing 2 weeks
1 month
Other
Signature
*
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