Empowered Living Online Coaching Application
Online Application  -   Applications that are not completely filled out will NOT get a response
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Email *
First and Last Name (What you want to be called) *
Sex *
Date of Birth *
Phone Number - Please include country code if outside of the United States.  Please include area code if in the United States *
Mailing Address - please include Street Address, City, State and Zip Code
Which method of contact do you prefer *
What health issues or body challenges are you currently struggling with right now?  check all that apply.
 *
Required
Of all the above issues that you checked above, what is you single biggest health issue or body challenge and how is it impacting your life in a negative way.
What's stopping you from reaching your goals?
What kind of assistance are you looking for to help you achieve your health and fitness goals?  
Any other topics would you like to learn about (check all that apply)
Have you ever significantly invested in YOURSELF for your health before *
What kind of training are you looking for (check all that apply) *
Required
Are you looking for Online or In Person? *
Required
If looking for online training, have you ever had an online coach before?   *
If you answered yes to having participated in online coaching before, What was it for and what was your experience like?   If you have not participated in online coaching before, please put N/A *
Height *
Weight - (only needed if you are have weight  loss/fat loss goals)
Goals (choose all that apply) *
Required
If you answered other to the above please share
If you had to choose only 1 of the above, which would be the MOST important? *
What have you tried and has worked for you in the past?
What has not worked?
Do you have a specific timeline for achieving a specific goal?  If so, please specify.  If not then specify N/A *
Which type of progress is more important to you.             *
Required
If you are looking for immediate progress, please explain your short term goal.
What previous experience have you had with Yoga Asanas (poses), Pranayama (breath work)  or Meditation? *
Required
Do you currently have a Yoga practice of any kind that includes breath work or meditation? *
If you answered yes to the above, how often do you practice?  Give details like how many times a week and what your practice looks like.  
What previous experience have you had with exercise and using weights? Choose all that apply *
Required
Do you currently exercise?  If yes, how often and what do you usually do.  weights, cardio, classes etc *
Do you plan on exercising from home or in a commercial gym *
If you plan on working out from home, please list all equipment you have available at home.
What is your biggest struggle that is either stopping or slowing your progress toward your goal *
Anything else you would like to share or that I need to know?
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