Coaching Application

1
What is your FIRST NAME?* This field is required.
2
What is your LAST NAME?* This field is required.
3
What is your preferred EMAIL so we can get in touch with you about your application?* This field is required.
4
Which of the following best apply to you?* This field is required.
I have been diagnosed with IBS
I have suspected IBS, and/or struggle with painful bloat, gas, unpredictable bowel movements
I have been diagnosed with SIBO and/or IMO
I have GERD/ reflux
I want to improve my fitness & body composition
I am looking to make sustainable health changes
I want to improve my exercise performance & fuel training (endurance, weight lifting)
I want to improve my mood & energy
Other
5
Which statement best describes where you are right now?* This field is required.
I’ve been dealing with my health and fitness challenges for at least a year and/or as long as I can remember – I need help!
I have been struggling for 3-6 months months, but ready to stop trying to figure it out on my own
I’ve just recently been curious to seek support for my gut health and fitness goals, but not sure I need expert support.
6
If you could have any wish granted when it comes to your health and wellbeing, what would you want your life to look like in 6-months from now?* This field is required.List key outcomes and how you wish to feel.
7
What do you need immediate help with in order to feel more confident with your health in the next 6 months?* This field is required.
I need help feeling more confident and less stressed around food choices
I need help with reducing painful gut symptoms
I need help knowing what supplements, foods and habits are right for me & my goals
I need guidance and accountability to keep me motivated and on the right track
I need help increasing my energy and mood so I can actually implement the changes I know I need to make
Other
8
Have you worked with a Dietitian before?* This field is required.
Yes
No
9
What prompted you to reach out to Leigh to help you achieve your digestive health and/or performance goals? Why did you feel working together would be a good fit for you?* This field is required.
10
My coaching programs are designed for motivated individuals ready to take action and implement meaningful change to improve their IBS/gut health and fitness, and reclaim their wellness. Which statement best describes you right now?* This field is required.
I’m beyond ready to take the next step!
I’m a little nervous but I know this is what I need now
I’m just curious.
11
My coaching takes place virtually (through a comprehensive nutrition platform and phone or online/video chat appointments). Are you comfortable with virtual coaching only at this time?* This field is required.
Yes
No
12
My coaching programs range from $315 - 460 CAD per month investment and a 6 month commitment depending on the level of support provided and the specific program option chosen. How ready are you to invest your time and resources into improving your health?* This field is required.Payment plans are available, as well as ongoing coaching support past 6-months.
Very ready: I know that investing in my health is what I need and I am ready to feel better and support my health for the long-term.
Somewhat ready, but not quite right now. This will be possible in 2-3 months.
Not ready: I am not in a place where I can invest in my health at this time.
13
What is your instagram handle if we are unable to reach you by email about your application?* This field is required.If you do not have instagram, feel free to share your Facebook handle or simply leave blank.
14
Which COUNTRY do you currently reside in?* This field is required.
Canada
United States
Australia
United Kingdom
Other
15
What is your PROVINCE or STATE?* This field is required.
16
Please confirm you are at least 18 years of age.* This field is required.
Yes
No
17
Please include any additional information you would like me to know here.* This field is required.
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