Request a Coach

Interested in 1 on 1 coaching? Fill out some info and we will be in

touch shortly! We can't wait to help you reach your health goals!

Thank you for your interest in our 1-on-1 health coaching program! This application helps us get to know you better and understand your goals, challenges, and expectations. Please fill out the form thoroughly, as this will help us tailor our sessions and get you started in a way that meets your unique needs.

Name

First Name

Last Name

Phone

(###)

###

####

Birth Date

YYYY

Location (City/State)

Which coach would you like to work with?

Health and Wellness Goals

1. What are your top 3 health goals right now? 2. Why is now the right time for you to pursue health coaching? 3. What specific areas would you like to focus on during coaching? (e.g., nutrition, fitness, weight management, muscle building, hormone balance, sleep, stress management, etc.) 4. How would you define success in this program?

Current Health & Lifestyle

1. Describe your current health status (e.g., any medical conditions, past injuries, hormonal imbalances, etc.): 2. What does your typical day look like? Include a brief summary of your usual meals, exercise, and stress levels: 3. Are you currently following any specific nutrition or fitness programs? If yes, please describe: 4. On a scale of 1-10, how would you rate your current energy levels? 5. Do you have any dietary restrictions, allergies, or food sensitivities? 6. What is your sleep routine like (bedtime, wake-up time, quality of sleep)? 7. What is your current level of physical activity (type and frequency of exercise)?

Mindset & Motivation

1. What are your biggest challenges when it comes to your health and wellness? 2. What has held you back from reaching your health goals in the past? 3. What motivates you to stick with a health and wellness routine? 4. How committed are you to making changes to improve your health on a scale of 1- 10 (1 = not committed, 10 = fully committed)? 5. Do you have any concerns or fears about starting this coaching program?

Program Expectations

1. What do you expect from me as your health coach? 2. How much time are you willing to commit each week to work on your health goals (e.g., meal prep, exercise, journaling, self-care)? 3. Is there anything else you'd like me to know before we start working together?