Wellness Support and Accountability Questionnaire
First of all, WELCOME and CONGRATULATIONS!

You have just completed the FIRST and most important step of your personal health and fitness journey by clicking on this form. That means that you are ready and considering taking on something that could potentially change your life.

Don't worry, though! As your Fitness Motivational Partner I am here to work with you to identify and implement the tools that are missing from your current fitness routine and shower you with positive vibes as you transform your body and mind to be the best version of yourself.

Please complete these questions as honestly as possible so that I may best support you in reaching your goals. I appreciate you trusting me to help guide you on your journey and I will keep your information in the strictest of confidence.

I'll do my best to get back to you within 48 hours with answers to your questions, details about my accountability groups or helpful next steps on your journey. I look forward to working together to keep moving forward towards your best self.

Yours in wellness,
Adina
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Email *
First Name *
Last Name *
Phone Number *
Social Media Handles (Facebook, Instagram) *
Where do you live? *
How did you find out about me? *
Which kind of program are you interested in? *
Required
Have you defined or are you currently working towards a specific health & fitness goal? *
If yes, please tell me about your goal *
What kind of accountability are you looking for? *
Current Fitness Level *
Please tell me what you currently do for fitness. What activities? How long? How often? *
Have you ever worked or are you currently working with a Coach?
Clear selection
Please tell me your experience with working with a coach. (If you have never had a coach, write no coach) *
Tell me what you eat in a normal day. Be as detailed as possible (please include dietary restrictions/allergies). *
Regarding Daily Eating Habits, I consider myself to be *
Not so Healthy / Not sure what to do
Very Healthy / Have a good routine
Current struggles (select all that apply) *
Required
Do you have any injuries or restrictions that I should know about? *
Do you have any questions for me? *
When do you want to start? *
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