DRXIVEN LLC Health Coaching Application Form
1:1 Health coaching consists of 30-min weekly virtual (Zoom) sessions and in-between session messaging and monitoring
Basic Info
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Goals
What are your primary health and fitness goals right now? [Be as specific as possible - weight loss (how much?), muscle gain, improving labs, drop a current habit, gain a specific habit, etc.]
*
Why are these goals important to you right now?
*
What happens if you don't make the necessary change(s)?
*
Current Status
Age
*
Height
*
Weight
*
Have you been diagnosed with any of the following?
*
Prediabetes
Type 2 Diabetes
High Blood Pressure
High Cholesterol
Other
None
If you selected "other" please specify below
Are you currently taking any medications? (optional but helpful for coaching context)
History
What have you tried in the past to reach your goals?
*
What do you feel has held you back from success?
*
Consistency
Lack of structure
Lack of accountability
Time constraints
Knowledge
Other
If you selected "other" please specify below
Lifestyle & Habits
How many days a week are you currently exercising?
*
0-1
2-3
4-5
6+
How would you rate your nutrition right now?
*
Poor
Average
Good
Very good
How would you rate your sleep?
*
Poor
Average
Good
Very good
On average, how many hours of sleep do you get per night?
*
Commitment Level
On a scale of 1-10, how ready are you to make a serious change?
*
Worst
1
2
3
4
5
6
7
8
9
Best
10
1 is Worst, 10 is Best
How many hours per week can you realistically commit to your health?
*
On a scale of 1-10, how willing are you to follow a structured plan with coaching guidance and accountability?
*
Worst
1
2
3
4
5
6
7
8
9
Best
10
1 is Worst, 10 is Best
Expectations
What are you looking for most in a coach?
*
Accountability
Structure
Knowledge & Education
Personalized Approach
Support without judgment
Results
Other
If you selected "other" please specify below
Availability
Select your preferred availability (Mountain Standard Time - MST)
*
Monday 5pm-7pm
Tuesday 5pm -7pm
Wednesday 5pm-7pm
Thursday 5pm-7pm
Friday 5pm
Saturday 6am -12pm
Sunday 6am-11am
Investment
Coaching packages range from $599 to $1499 depending on duration and level of support. Are you prepared to invest in coaching if it's a good fit?
*
Yes
No
Need more information
Which 1:1 weekly coaching package are you interested in?
*
$599 - 4 weeks
$1499 - 12 weeks
Final Questions
Why do you believe DRXIVEN is the right fit for you?
*
Preferred mode of communication
*
Phone
Text
Email
Acknowledgment
*
If selected, by submission of the application, I give permission to be contacted by any of my preferred modes of communication. Typical timeframe to be contacted is between 24-72 hours.
Submit
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