Apply for a FREE Consult Here
This short form will just take a few minutes and will greatly help me prepare for our first session together.  Your goals are very important to me and I want to know how I can best support you in reaching them!  

It's important to get to know each before we consider whether health coaching is right for you. There is space below for you to ask me any questions you have as well.

In our health coaching sessions, together we will create a process that maximizes your potential to make and sustain healthy change.  I'll teach you techniques that you'll use between sessions and support you with gentle accountability that will get you across the finish line!  

After you fill out this short form, I will contact you to go over details and availability before the appointment is scheduled. If you would like faster service and direct information on my coaching programs, please contact me at (928) 362-1132 or beth@purehealthysolutions.com

These techniques require time and effort and results may vary depending on many factors. This survey does not guarantee results nor establish any agreement to continue on either of our parts. It is completely risk free and I will hold any information disclosed in confidence.

Let's get started.

Sign in to Google to save your progress. Learn more
Email *
Are you a new or existing client?
Clear selection
What prompted you to find out about health coaching? *
In a few words, let me now why you're interested in having a consultation with a certified health coach.
Describe your most important concern or challenge related to health and wellness. *
Let me know your most pressing health concern(s) so I can better plan our session together. It might be "lose weight", "learn more about healthy eating", or "improve my energy", or any other health or wellness related interest or concern.
Are you under the care of a doctor or other healthcare provider or taking any prescription medication? I recommend consulting with your health care provider before initiating any changes to diet, activity, or lifestyle. *
Required
What are your top results you'd like to achieve when working with a health coach? *
Think big here! If you could have whatever wish for your health, what would it be? Try to be as specific as possible. For example, "I'd like to be able to have more willpower over what I eat" or "I want to wake up feeling energized and refreshed every morning". These are just examples so please, list whatever is meaningful to you here.
How would it feel for you to reach those goals? *
You could describe what you might feel when you achieve your health and wellness goals or what it allow you to do or even what it would mean to you.
Regarding your main concern, what have you tried in the past and how well did that work for you? *
Please share what, if any, other things you've tried to reach your health and wellness goals. It might be a particular diet or exercise program, for example.
Are you at the point where you really want to make positive changes and are ready to take action? *
Required
Contact info
Please fill in your contact information below. Complete the option that is the best way to get in touch.
Your name *
Phone number
E-mail
Preferred contact method *
Required
Questions and comments (optional)
Next
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms