Private Coaching Application — Work with Jillian
Please complete this form to share your health journey and coaching preferences. Have your details ready to help us connect effectively.
Applicant Information
Full Name
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First Name
Last Name
Email Address
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example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
How did you hear about Jillian?
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Please Select
Nourish & Flourish community
Referral from a friend or client
Instagram
Facebook
Google search
Other
Health Background
In a few sentences, what is bringing you here right now? What's going on with your health?
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How long have you been dealing with these health concerns?
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Please Select
Less than 6 months
6 months to 1 year
1–3 years
3–5 years
More than 5 years
What have you already tried? Please share any diets, programs, doctors, supplements, or approaches you've explored.
Goals, Readiness, and Fit
What would feeling truly well look like for you? If everything shifted, what would be different?
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What feels like the biggest barrier standing between you and your health goals right now?
On a scale of 1–10, how ready are you to make real changes right now?
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Please Select
1–2 Just exploring
3–4 Curious but hesitant
5–6 Ready but nervous
7–8 Ready and motivated
9–10 All in
Which coaching option feels most aligned with where you are?
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Please Select
Weekly sessions — $600/month (most support)
Biweekly sessions — $400/month (most popular)
Monthly sessions — $200/month (maintenance)
Not sure yet — open to discussing
Are you able to invest in your health at this level for at least 3–6 months?
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Please Select
Yes — I'm ready to commit
I think so — I'd like to talk it through
I'm not sure — finances feel tight right now
Is there anything else you'd like Jillian to know before you connect?
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