Welcome!
Initial Consultation & Waiver Form
Name
*
First Name
Last Name
Email Address
*
Mobile Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Postal Address
*
Address
Street Address Line 2
Suburb
State
Post Code
Date of birth
*
-
Day
-
Month
Year
Which coaching option are you signing up for?
*
Platinum 1:1 coaching - fortnightly check ins - $55 per week
Nutrition 1:1 coaching - fortnightly check ins - $40 per week
Fitness 1:1 coaching - fortnightly check ins - $30 per week
Occupation
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Your current weight (KG)
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Your current height (CM)
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When do you wish to start?
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ASAP? Or do you have a certain date in mind?
How did you hear about me?
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If you heard about me or were referred from a specific person please add their name! :)
Goals
Why do you want a coach?
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What do you expect from me?
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What are your goals in regards to health and nutrition?
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What has stopped you from achieving your goals so far?
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How committed are you to this journey right now?
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Lifestyle
How many hours of sleep do you get per night?
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What is your general bed time?
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What time do you generally wake up?
*
How much water do you drink per day?
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Please Select
Less than 1L
1L
1.5L
2L
2.5L
3L
More than 3L
Do you drink coffee regularly?
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Yes
No
How many per week?
Do you drink alcohol regularly?
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Yes
No
How many per week?
Who lives with you at your house? Please specify ages
*
This is to determine who you are cooking for - just yourself, or do meals need to suit a family with a range of ages
Do you follow a specific diet?
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Please Select
No
Vegan
Vegetarian
Pescatarian
Other
How busy is your day to day life? Detail a "normal" day for you. The more info, the better!
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This is to determine how much time you have to prep food. Give me an outline of your working days, down time etc.
What are some things you really enjoy doing? Any hobbies, self care activities?
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Food
Have you ever tracked macros or calories before?
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Yes - macros and calories
Yes - Calorie counting only
No
How many calories do you usually consume?
How often do you consume fast food?
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Please Select
Multiple times per week
Once a week
Once a fortnight
Once a month
Once every 6 months
Never
Foods you enjoy?
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Foods you dislike?
*
Any food allergies?
*
Outline a typical day of eating for you - include all meals and snacks (no wrong answers!!)
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How many meals do you wish to eat per day (including snacks)?
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Please Select
Three
Four
Five
Six
Exercise
Please be realistic and do not exaggerate
Do you currently exercise?
*
Yes
No
How often?
Please Select
Once a week
Twice a week
Three times a week
Four times a week
Five times a week
Six times a week
Seven times a week
If yes - please detail types of exercise
How active are you in your day to day activities?
*
Please Select
Sedentary - Sitting for most of the day
Lightly active
Somewhat active - Spend a good portion of the day on my feet
Very active
Extremely active - physically demanding job
Do you have a step counter? (Smart watch etc)
*
Yes
No
What are your average daily steps?
Health summary
Please note: certain answers to the below questions will require a medical clearance before I can work with you
Section A
Rows
Yes
No
Are you pregnant or breastfeeding?
Have you been diagnosed with an eating disorder?
Have you been diagnosed with diabetes?
Have you been diagnosed with chron's disease?
Have you been diagnosed with cancer?
Have you been diagnosed with IBS?
Have you been diagnosed with Inflammatory Bowel Disease?
Have you been diagnosed with renal disease?
Do you have any chemical sensitivities?
Have you been diagnosed with infertility?
Have you had gastric bypass surgery within the past 2 years?
Do you have any of the following: Ulcerative collitis, Diverticulitis, Bowel obstructions, or bowel resections?
Section B
Rows
Yes
No
Do you have high cholesterol?
Do you have high blood glucose levels?
Are you taking any prescribed medications? (if yes, please advise medications in the box below)
Have any of your family members had a history of any of the chronic health conditions outlined in section A (above)?
Medications
Section C
Rows
Yes
No
Do you experience bloating regularly?
Do you believe you suffer from excessive flatulence?
Do you experience irregular bowel motions? (diarrhoea, constipation, abnormal colours, urgency)
Do you believe you suffer from low energy levels?
Client waiver
I have filled out this form honestly and will update Nurture by Steph of any changes to my medical status
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I agree
I understand that all information given by Nurture by Steph is guidance only and not to be taken as medical advice
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I understand
I agree to pay the set up fee (if required) as well as weekly fees for the duration of my coaching with Nurture by Steph
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I agree
I understand there is a minimum 12 week commitment to nutrition coaching services, and that 14 days written notice must be given prior to cancelling any coaching services
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I understand
I understand there is a minimum 4 week commitment to meal planning services
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I understand
I understand that all documents given to me are the property of Nurture by Steph and must not be duplicated or redistributed
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I understand
I agree to allow Nurture by Steph to use my before & after photos for marketing purposes
*
I agree
I do not agree
Signature
Today's Date
-
Month
-
Day
Year
Date
Important - Please read!
You will be taken to a payment page at the end of this form. Please pop in your card details to purchase your membership. You will then be sent an email to activate your purchase - once you have done that, you will be able to login to my client app and I can start setting up your file from my end. If you have a discount code, please ensure you enter this on the payment page (if you pass this page without entering, there is nothing that can be done from my end)
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