Clean Keto Lifestyle 1:1 Coaching Application
This questionnaire should only take about 10 minutes to complete. Consider it your first step to truly investing in your health!

Quick note: Please only apply if you are a serious applicant. This program is a 6 month total transformation and a long-term, sustainable solution. It's our most personalized, results-drive program.

If you are not ready to commit time, energy, and space to the process, please wait and apply later when you are ready. Our goal is to help you achieve the BEST possible results using a truly individualized approach, which involves nourishment, lifestyle, habits, stress management, and mindset.
Sign in to Google to save your progress. Learn more
CLIENT SUCCESS STORIES
Email *
First Name *
Last Name *
Phone Number *
Age *
Gender *
Occupation  *
What are your goals? Please be as specific as possible (i.e. heal your body, lose weight, look and feel better, learn how to stay consistent, have more energy, etc.).
 *
What are your biggest struggles when it comes to healthy eating? Please check as many as apply.
 *
Required
What nutrition programs or diets have you tried in the past that have not worked?
 *
Are you currently pregnant, postpartum, breastfeeding, or trying to conceive?
 *
Do you have a diagnosed health problem? If so, please elaborate.
 *
What do you REALLY want to achieve by working with a coach? What awesome things would happen?
 *
What do you think is holding you back from your goals?
 *
How do you like to be coached? Do you prefer a warm-fuzzy approach or tough love? Something else? What approach do you respond to best?
 *
On a scale from 1-10, how committed are you to achieving your goals?
 *
Not committed
I'm ALL IN. Let's do this!
Working together is a 6 month commitment so that we can use nutrition & lifestyle changes most effectively. Is that a problem for you?
 *
Our high-level coaching program requires a significant investment starting at $3,000 (or $500 a month). Are you ready to invest in yourself?  
 *
Anything else you'd like for us to know?
 *
MORE CLIENT SUCCESS STORIES
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Clean Keto Lifestyle. Report Abuse
Google Forms