Coaching Application

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Email *

Name *

City, state, country

Phone *

Biological Sex

Male

Female

Prefer not to say

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Current Weight

Height

Goal

Fat loss

Muscle Gain

Performance

Maintenance

Other:

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Current activity level

Sedentary (desk job, less than 5000 steps)

Somewhat active (teacher, 5000-7000 steps)

Moderatley active (nurse, 7000-10,000 steps)

Very active (construction, 10,000+ steps)

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Do you train?

Yes

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Name of gym

What style of training do you engage in?

Cardio

Lift

HIIT

Combination

None

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What diets/nutrition plans have you tried in the past?

What has been your biggest success?

Where have you seen the most struggles?

What is your biggest challenge when it comes to nutrition? *

Planning

Environment (food in the house/office/etc)

Social situations

Travel

Emotional Eating

Not knowing what to eat

Not knowing how much to eat

Other:

When you think of "healthy" foods, what are the first 3 that come to mind?

When you think of "unhealthy" foods, what are the first 3 that come to mind?

List preferred protein sources

List preferred carb sources

List preferred fats

How did you hear about Food on the Mind?

Anything else I should know?

I acknowledge that I am aware that Food on the Mind, LLC its members, officers, agents, employees and independent contractors are not medical doctors and do not diagnose disease. I also acknowledge that I have been warned that I should consult a Physician before undergoing any dietary or food supplement changes. I also affirmatively state that I have disclosed any and all known medical or genetic conditions, medications I use, and any significant personal or family medical history. Any recommendations that I follow for changes in diet, including but not limited to the use of food supplements, are entirely my choice and my responsibility. I am knowingly assuming any risk associated with nutritional counseling.In consideration of my participation in nutrition counseling, I hereby accept all risk to my health and of my injury or death that may result from such participation and I hereby release Food on the Mind, LLC, its members, officers, agents, employees and independent contractors from any liability whatsoever to me, my personal representatives, estate, heirs, next of kin, and assigns for any and all claims and causes of action for loss of or damage to my property and for any and all illness, injury or other harm to my person, including my death, that may result from or occur during my participation in nutrition counseling, whether caused by the sole or concurrent negligence of Food on the Mind, LLC, its members, officers, agents, employees and independent contractors.I further agree to indemnify and hold harmless the Food on the Mind, LLC, its members, officers, agents, employees and independent contractors, to the fullest extent permitted under law, from any and all liability for the injury or death of any person(s) and damage to property that may result from my negligent or intentional act or omission while participating in the described nutrition counseling session. I HAVE CAREFULLY READ THIS AGREEMENT AND UNDERSTAND IT TO BE A RELEASE OF ALL CLAIMS AND CAUSES OF ACTION FOR MY INJURY OR DEATH OR DAMAGE TO MY PROPERTY THAT OCCURS WHILE PARTICIPATING IN NUTRITION COUNSELING AND OR DEATH OF ANY PERSON AND DAMAGE TO PROPERTY CAUSED BY MY NEGLIGENT OR INTENTIONAL ACT OR OMMISSION. *

By checking this box I am assigning my signature in agreement with the above waiver

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