Clone of Donna Results Consult Intake Form

The Basics
Full name

First NameLast Name
Phone Number
Email
example@example.com
What is your commute time to the studio?
Please list everything you do currently for fitness and wellness.
What of the below would you like to achieve in the next 3 months?

Fitness IncreaseBetter EnergyWeight LossStrength GainImproved Mental HealthSkill IncreaseTone UpHabit CreationLifestyle AdjustmentOther
What is your top fitness and wellness goal for this year?
What does that goal mean to you?
How will your life change when this goal is achieved?
Do you have a timeline to achieve your goal?

How motivated are you to reach that goal? (1 = not a top prioirty, 5 = nothing is more important)

	1	2	3	4	5

1 is low , 5 is High

What are you most excited about exploring at REV36O? (choose all that apply)

CyclingStrengthNutrition CoachingPersonalized DiagnosticsStress ReductionNervous System RegulationOther
Of the Below, what two are most important for you when participating in fitness & wellness options?

Community feelIntense trainingTop Tier CoachingSupport & GuidanceAccountabilityPersonalization & CustomizationResultsBudgetOther
Of the below, what would be your preference?

In person training - I thrive on the group motivationVirtual works best for meA hybrid of in person and virtual would be great for me.
If you knew your goal was possible, how much are you willing to spend per week to reach your goal?

$25-$35 per week$35-$45 per week$45-$55 per weekUp to $100 per weekOther
If you could pay with a payment plan or use your HSA/FSA, would this make a difference?
In households, there is often more than one person making finaincial decisions. Will you commit to discussing your budget prior to our consultation so that is not a barrier to your reaching your goals?
What else do your want the consultant to know before your appointment?
Important Notice & DisclaimerThe information provided in this intake form and during your consultation is for educational and informational purposes only and is not intended to diagnose, treat, cure, or prevent any medical condition. Your consultation does not replace medical advice from a licensed healthcare professional.Before beginning any new exercise, nutrition, or wellness program, you are encouraged to consult with your physician or qualified healthcare provider, especially if you have any pre-existing conditions, injuries, or health concerns.While we will use our expertise to guide and support you based on the information you provide, your results depend on many factors, including consistency, effort, lifestyle choices, and individual circumstances. Because of this, we cannot guarantee specific outcomes or results.By proceeding, you acknowledge that you are voluntarily participating and accept full responsibility for your health and well-being.
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The Basics