1. Name *

First Name

Last Name

3. Phone *

(###)

###

####

4. Preferred method of communication: *

Phone

Email

Text

5. What are your goals in pursuing nutrition coaching?

Check all that apply.

Lose weight

Gain muscle

Overall wellness

Improve athletic performance

Other (explain below)

9. Dedication level:

1 - Totally in 100%

2

3

4

5 - eh, interested but don't want to make big changes

11. How often do shop for groceries or get groceries delivered?

Rarely or Never

1x per month

1x per week

12. How often are you eating out or having takeout delivered?

Rarely or Never

1x per month

1x per week

More than 1x per week

15. Did you struggle with weight as a child?

Yes

No

16. How many times do you usually work out in a week? *

0

1-2

3-4

5+

18. How active are you during the day outside of your workouts? *

Not active at all

Some activity

Very active

20. How often do you travel?

Never or Rarely

1x per month

1-3x per month

1x per week or more

21. How many hours of sleep do you get on a typical night?

Less than 5

6 or 7

8 or more

28. Do you prefer a male or female coach?

I prefer a male coach

I prefer a female coach

I don't care

29. I prefer to be billed:

the full amount in one payment

divided into three monthly payments