1:1 Coaching — Application

Full Name* This field is required.

First Name

Last Name

Preferred Name (if different)

Email Address* This field is required.

example@example.com

Phone Number

Please enter a valid phone number.

What is your current age?* This field is required.

Which best describes your current hormonal stage?* This field is required.

Perimenopause

Menopause

Postmenopause

Not sure

If you want, share a bit about your current life context (work, family, major changes, etc.)

Have you ever been diagnosed with any hormonal conditions (e.g., PCOS, thyroid, endometriosis)?

Yes

If yes, please specify (diagnosis, year, and any treatment):

Are you currently taking any hormone therapy or related medications?

Yes

If yes, please list medication(s), dose, and how long you’ve been on them:

How would you describe your typical energy through the day?* This field is required.

Consistently steady

High in morning, drops in afternoon

Low all day

Varies day to day

How often do you experience strong cravings for sweets or carbs?* This field is required.

Rarely

A few times a week

Most days

Daily

Do you ever feel shaky, lightheaded, or irritable if you go too long without eating?

Yes

How would you rate your overall stress level lately?* This field is required.

Low

Moderate

High

How many hours of sleep do you typically get per night?* This field is required.

Less than 5

5-6

6-7

7-8

More than 8

Do you have trouble falling or staying asleep?* This field is required.

Rarely

Sometimes

Often

How would you describe your mood most days?* This field is required.

Mostly positive

Up and down

Low or flat

Do you experience any of the following regularly? (Select all that apply)

Hot flashes/night sweats

Weight changes

Bloating/digestive issues

Joint/muscle aches

Brain fog

Sleep disruptions

Low libido

Other

If you selected 'Other', please specify:

How would you describe your current physical activity level?* This field is required.

Mostly sedentary

Lightly active

Moderately active

Very active

How many meals do you typically eat per day?* This field is required.

How often do you eat snacks between meals?* This field is required.

Rarely

A few times a week

Most days

Daily

Do you ever skip meals?* This field is required.

Rarely

Sometimes

Often

Do you follow any particular dietary pattern or restrictions?

Vegetarian

Vegan

Gluten-free

Dairy-free

Low-carb

Other

If you selected 'Other', please specify:

Who do you live with?

Alone

Partner/spouse

Children

Other family

Roommates

Other

If you selected 'Other', please specify:

How much support do you feel you have for making health changes right now?

A lot of support

Some support

Minimal support

No support

What are your top 1–3 goals for coaching?* This field is required.

How ready do you feel to make changes right now?* This field is required.

Very ready

Somewhat ready

Not sure

What, if anything, do you feel might get in the way of your success?

Have you worked with a coach or nutritionist before?

Yes

If yes, what worked well and what didn’t?

What are you hoping for in a coach-client relationship?

What time zone are you in?

Are there days/times you absolutely cannot meet for sessions?

Anything else you’d like to share that would help us understand you or your goals?

I understand this is an application only, and completing it does not guarantee a spot in the 1:1 coaching program.* This field is required.