Wellness Survey
After you fill out this form, I will contact you to go over your answers and help you choose the best options to reach your personal goals.
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Email *
Name (first & last) *
Phone
Please tell me a little about your goals? Do you want to lose weight (if so, how much), tone up, eat better, gain more energy, improve your self-confidence, etc.?  *
If you knew you would not fail, how would you ideally like to feel in 3 months/1 year? *
How would you rate your overall motivation to change your health & wellness? (1-5) *
Mindset wise, what has held you back from reaching your goals? (do you struggle with needing support, accountability, developing consistency, feeling overwhelmed, emotional eating, peer pressure etc?)  *
Please rate your energy level. (1-5) *
If you were to begin a fitness program, what kind do you think would be the most rewarding for you? *
Rate your digestive health (1-5) *
What are your biggest barriers to reaching your goals right now? *
How would you rate your nutrition? (1-5) *
Give me a glimpse into your nutritional habits. Do you feel like you know what and how much to eat for healthy balanced nutrition? Do you eat on the go a lot? Have you ever struggled with emotional/stress eating? Are you a chronic dieter? Do you feel guilty/sabotage when you treat yourself? Do you have good self control when it comes to junk food/sweets? Any specific cravings?  *
Are you willing to invest in a nutrition program so that I may better coach you towards achieving your goals?  *
With your purchase you have the option to get a 1 month supply of a botanically rich, whole food shake that supports your health + energy  with superfoods, pre and probiotics, digestive enzymes, adaptogens & phytonutrients at a SUPER discount! (Wheat, Nut & Soy Free) Which flavor would you like to try first?  *
You can also try our performance line in addition to, or in place of, the botanical shakes.  These are:  Recover- to prevent Delayed Onset Muscle Soreness.  Energize- to boost energy levels for a workout or just bump up your energy during the day.  Beachbars (can be added with either the performance line or the shake)- Healthy quick snack 10g protein, 4g fiber, & only 6g sugar *
Do you have any questions for me?  How would you prefer to be contacted?  Phone, text, video chat, messenger, email? *
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