A2Z Coaching Lifestyle Questionnaire

Please Complete This Application

If we don't get an application from you, your booking WILL BE CANCELED. Please BE HONEST.
Name*

First NameLast Name
email address*
example@example.com
Phone Number*

Area CodePhone Number

What is your goal? Lose 20 lbs? Gain 20 lbs. of muscle? Overcome depression? Be specific. Doesn't just have to be a physical goal.*
What would be the most important criteria for your success as we work together?*
What have you tried in the past and why hasn't it worked for you? What's stopping you from hitting your goal?*
On average how much money do you spend on coffee or energy drinks each week? If none put N/A
On average how much money do you spend on eating out each week?
On average how much money do you spend on alcohol each week?
On average how much money do you spend on tobacco or nicotine each week?

On a scale of 1-10... 1 being I'm satisfied where I am and 10 being I'll do anything to reach my goal. What number are you?*
YesNo
Yes - I need this.No my health is not a priority.
YesNoNot applicable

What is GOOD about NOT changing? What is working for you with the status quo? What are the benefits of staying the same
What would be BAD about changing? If you changed, what might you have to give up or lose? How would your regular routine be interrupted?
What would be GOOD about changing? If you changed, how would the helpful or beneficial? What new oppurtunities or possibilities could open up?
What might be BAD about NOT changing? If you didn't change, what bad things could happen?
If you keep going the way you're going, what might things look like in the future (say, 10 years from now?)
My coaching is about teaching, not just ordering you around.

After the program you should never need another coach or program again because I'll teach you every last trick in the book pertaining to diet and exercise - This is a lifestyle adjustment.
With that said, are you ready RIGHT NOW to move forward? (Be ready to move forward on the call IF YOU and me decide you're a good fit for this program. IF you are not a good fit I will let you know and refer you to someone else) *
If accepted how soon are you looking to get started? (if you aren't ready please just wait and schedule when you can - No worries. Just remember, results take action ) *

Please Complete This Application