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Health & Fitness Program Application
Tell me a little about you and your wellness goals and let's get you there :)
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Email
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Your answer
Phone
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Your answer
Name (first & last)
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Your answer
Instagram handle or Facebook name
Your answer
How do you prefer to be contacted?
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Text message
Email
Instagram
Facebook
Other:
Where is your country of residence?
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USA
Canada
UK
France
Other:
Today's date
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MM
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YYYY
When is your birthday?
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Your answer
How did you find me?
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Your answer
If you knew you would not fail, where would you ideally like to see yourself in 90 days? Think physically, emotionally, mentally, spiritually, life goals, etc.
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Your answer
Are you willing to invest in a fitness and nutrition program so that I may coach you towards achieving your goals?
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Your answer
What are your health & fitness struggles currently? Please be specific. (Address digestive health, energy level, any weight loss/gain goals, hormonal balance, pain, inflammation, etc.) The more details, the better.
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Your answer
Please rate your energy level:
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You can barely get out of bed
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You don't drink any stimulants and have vibrant energy all day
Please rate your digestive health:
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Poor
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Flawless!
Please rate your stress level:
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Unbearable, constantly stressed
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You're on a beach relaxed :)
Please rate your quality of sleep:
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HORRIBLE. I get 3-5 hours of sleep per night :(
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Amazing! I sleep like a baby most nights up to 7+ hours!
Please rate your level of confidence in your ability reach your goals:
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I don't believe I'll ever be successful...
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I KNOW I WILL BE SUCCESSFUL if I persevere & set my mind on it!
What are your biggest barriers to reaching your goals right now? Why have you not been successful in the past?
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Your answer
Which nutritional approach do you feel you'd benefit from more?
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A program with more structure. You'd be told exactly how many portions of each food group to eat every day based on your goals and starting point. It would include training on the reasons why we crave certain foods, why we use the macronutrient breakdown we do and why portion control is important to be successful in your goals.
A program with more flexibility. With this approach, you could make it work even while traveling or eating out at restaurants because you'll learn how to plate each meal. There are no food lists or counting involved. It is created especially for those who have a negative relationship with food such as emotional eating, stress eating, chronic dieters, or those who starve & binge eat. It's a shift in mindset more than anything. You'd learn how to say YES to the right foods instead of focusing on saying no to the wrong foods.
I'm not sure.
Do you currently have any food sensitivities? If not sure, take the test in the links on my page, or go to your doctor. Do you have a nutrition plan or guide that you follow?
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Your answer
Would you be interested in doing a 3-Day Cleanse to jump start your metabolism and help banish belly bloat?
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Yes
No
Maybe
Please check which fitness equipment you have at home:
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Dumbells
Aerobics Step
Pull-Up Bar
Exercise Bands
Yoga Mat
Other:
Required
Are you interested in Energize (a plant-based pre-workout/energy booster)?
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Yes - Lemon
Yes - Fruit Punch
Yes - Mixed Berry
No
Maybe
Are you interested in Recover (BCAA's formula to reduce muscle soreness and improve muscle building)?
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Yes - Chocolate
Yes - Orange Creamsicle
Yes - Vegan Chocolate
No
Maybe
Are you interested in Bevvy (A delicious tea to help crush cravings and chronic snacking)?
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Yes - Original
Yes - Lemon
Yes - Pomegranate Berry
Yes - Focused Energy
No
Maybe
Are you interested in Beachbars (our clean-eating protein snack bars)?
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Yes - Peanut Butter Chocolate
Yes - Chocolate Cherry Almond
Yes - Vegan Chocolate Almond Crunch
No
Maybe
Are you interested in Collagen scientifically proven to improve skin, nails + hair in just 30 days?
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Yes
No
Maybe
I usually recommend my clients start with a powerful foundational supplement called Shakeology. It is an incredibly dense formula that supports the body in several capacities with over 70 superfoods per serving. What flavor of Shakeology would you like to try first? (Vegan options are best for those with digestive sensitivities.)
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Vanilla
Chocolate
Strawberry
Cafe Latte
Vegan Chocolate
Vegan Vanilla
Vegan Tropical Strawberry
Vegan Cafe Latte
Vegan Salted Caramel
Are you interested in a preferred customer membership? (You can register for FREE to get all your supplements/goods at wholesale cost with a $9-$25.00 monthly membership fee. Think Costco! Big savings!)
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Yes
No
Maybe
Are you interested in learning more about becoming a coach yourself or joining our team ambassador program?
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Yes
No
Maybe
Anything else you would like to add about your situation?
Your answer
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