Weight Loss Coaching Intake

Weight Loss Coaching Intake

Complete the intake form below to schedule your 30 minute consultation. All initial consultations are virtual.
Name

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Email Address
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Phone Number
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What are your main goals or challenges regarding weight management?
What are your main goals or challenges regarding weight management?
How soon are you looking to start your weight loss program?
Any additional comments or questions?
How did you hear about me?
Schedule your initial consultation.

Privacy Policy

Ms. Kira Shay Wellness Privacy Policy. Your privacy is important to me. Information collected through this form may include your name, email address, phone number, health and wellness goals, lifestyle habits, and other information you voluntarily provide. This information is collected solely for the purpose of:Scheduling consultations. Providing wellness coaching services. Developing personalized wellness recommendations. Communicating regarding programs, services, and resourcesImproving client support and program delivery. Your information will not be sold, rented, or shared with third parties for marketing purposes. Information may be shared only when required by law or when necessary to process payments through authorized payment platforms. Please note that electronic communication methods such as email, text messaging, social media messaging, and online forms cannot be guaranteed to be completely secure. By submitting this form, you acknowledge and accept these risks. For questions regarding this policy, please contact: Fitcoachjak@gmail.com
WELLNESS CONSULTATION AGREEMENT
I understand that the services provided by Ms. Kira Shay Wellness are educational and coaching services only. I acknowledge that:Wellness coaching is not medical care.Ms. Kira Shay is not acting as my physician, nurse practitioner, therapist, registered dietitian, or mental health provider.Any recommendations provided are intended for educational and informational purposes only.I am responsible for consulting with my healthcare provider before making significant changes to my diet, exercise routine, supplements, or lifestyle.Results are not guaranteed.Individual outcomes vary based on personal effort, consistency, lifestyle factors, and medical history.I understand that participation in wellness coaching is voluntary and I assume full responsibility for my health decisions.By clicking below, I acknowledge that I have read and understand this agreement.
Consultation Payment Agreement
By booking a consultation with Ms. Kira Shay Wellness, I acknowledge and agree to the following: The consultation fee is:$30 Wellness Consultation Payment must be received before the consultation appointment is confirmed. Non-Refundable Fee: The consultation fee is non-refundable.This fee covers:Consultation preparation Appointment scheduling Professional wellness assessment Personalized recommendations provided during the consultation. Clients may reschedule with at least 24 hours notice. Failure to provide 24 hours notice may result in forfeiture of the consultation fee. Clients who fail to attend their scheduled consultation without notice will forfeit the consultation fee.Program Enrollment Participation in a consultation does not guarantee enrollment into any future coaching program. Any future coaching services will require a separate agreement and payment arrangement.
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