Weight Loss & 1:1 Coaching Interest Form

Are you inconsistent with your nutrition and exercise habits? Discouraged about how you look? Don't know where to start? Wanting to experience real change?

Then you're in the right place!

I am so excited to help you turn your health, fitness and wellness goals into a LIFESTYLE and a long term REALITY!

This form will just take 2-3 minutes to complete. Whether you are ready to start tomorrow, or still wanting to ask more questions, feel welcome to fill it out! I will reach out to you shortly to answer any questions you have & help guide you in your next steps.

I cant wait to get to know you better and help you experience a new, exciting way of life!

The more detailed and thoughtful your responses, the better I’ll be able to understand what’s going on and provide guided feedback tailored to your unique needs.

This is your opportunity to share everything that’s been on your mind so I can help you take the right steps toward feeling your best. Take your time, be as honest and specific as possible, and let’s get feeing like you again!

Full Name *

Email *

Phone # *

DOB *

Instagram Handle

How excited and ready are you to finally reach your goals?

SUPER Excited! When can we start?

Ready but nervous.

Not sure just want to learn more.

Are you currently on birth control? If yes which one? *

Tell me about your cycle. Is it regular, irregular, do you have heavy days, clotting, PPMD? *

Do you have any children? If yes please list their ages *

Do you have any current medical conditions? If so, please share how it affects you and anything I should know. Remember, to always check with your physician before making any lifestyle changes. *

How often do you have bowel movements? Please describe the consistency (e.g., hard, soft, loose, etc.) and any other characteristics you notice (e.g., color, frequency, discomfort). *

Please list any medication you are currently on. *

What goals are you looking to achieve in the next 6 months? *

Is there anything else you feel I need to know?

What have you tried to reach your goals already, and why did that not work?

If you could have your dream results in the next 4-6 months what would that look like? Be as detailed as possible.

Do you have a support system in this journey? Check all that apply *

All me I got this

Spouce/partner 100% supports me and want me to feel better

Spouce/partner is skeptical but will always support me

Spouce/partner doesn't really support me on this journey

No support just me and you girl

What is holding you back from reaching this goal? *

Would you like to learn more about how to work with me? *

Yes, but nervous

Yes I need this now!

Unsure but would love to chat

No just want your thoughts

I agree that by providing my contact information to receive messages from the business.