Consulting Application
Book your consultation call. There is a one-time $25 consultation fee upon completion
Full Name
*
First Name
Last Name
Gender
*
Male
Female
Date of Birth
*
Please select a month
January
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Month
Please select a day
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Day
Please select a year
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Year
Age
*
years
Height
*
Ex: 5'3"
Weight
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lbs
Day Phone
*
-
Area Code
Phone Number
Cell Phone
*
-
Area Code
Phone Number
E-mail
*
What are your goals?
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What concerns do you have about your health, fitness, and eating habits?
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Are you experiencing any stresses or motivational problems?
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Yes
No
Do any diseases run in your family?
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Yes
No
Do you suffer from diabetes, asthma, high or low blood pressure?
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Yes
No
Rate Your Current Fitness Level
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Couch Potato
Mall or Dog Walker
Weekend Warrior (you only partake in physical activities on weekends and nothing during the week)
Gym Member (you participate in moderate work outs in the gym 3-4 days per week for an hour or less each time)
Committed Gym Member (you have a routine 4+ days a week and you stick with it – but limited to hour long workouts like Cross Fit or Spinning classes)
Serious Fitness Buff (you work out vigorously 5+ days per week 90 minutes at a time and vary your routine with some intense workouts, hikes on hills and mountains. Your butt hurts after every workout)
Marathon Runner, Triathlete, Cyclist (longer distances and participate in organized local or national races)
What is your goal with your training?
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Why?
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Describe the last time you participated in a structured exercise program:
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What personal barriers do you feel are keeping you from reaching your nutritional and fitness goals?
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Lack of motivation
Time
Self Conscious
Lack of equipment
Lack of Results
Hitting A Plateau
Money
Not knowing where/how to begin
What do you expect from me as a Coach?
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Explain how you believe your diet is affecting your health goals:
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Have you had any recent weight gain or loss?
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Yes
No
If yes, please explain:
Please rate your readiness for change.
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10
Please rate your motivational level to do what it takes to reach your goal.
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2
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9
10
I have no motivation.
I'll do anything it takes!
1 is I have no motivation., 10 is I'll do anything it takes!
What motivates you?
*
Need a strong motivator to push you to exercise
You like to be informed about your program and how it is going to lead you to your goals
Like to try new things if they are effective
Willing to push past your comfort level to reach your goals
I feel things are really hard I tend to back off
Need to be held accountable for what I am doing
Signature
*
Date
*
*** TO SCHEDULE YOUR CONSULTATION, CLICK THE LINK BELOW ***
CONSULTATION LINK
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