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Client Application Form (Jennifer K. Wellness)
Please fill out this form so I can get to know you and understand what you're looking for guidance with. I will reach out to you via phone or email if I see that what you're looking for and what I can provide are a good fit. Note that what you write here will be kept confidential between the two of us. Thanks <3.
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Full name *
Today's Date *
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Phone number (with country code) *
Can I message you via whatsapp (if not I will email you)? *
Email Address *
Check this box to consent to receiving emails. This form allows me to collect info and keep you updated about future offerings and other wellness content. *
Required
Age *
Gender *
Which city and country do you live in? *
What are you looking for guidance with? *
What is/are the biggest challenge(s) you're facing with your food mindset and/or body image right now? *
Typical foods eaten in a day (if applicable)
Have you dieted before? If yes, approx. how many times and for what reasons? *
Do you want to lose or gain weight? If yes, which one? *
Have you struggled with an eating disorder now or in the past? If so, what? *
What are other health concerns I should know about? *
What forms of self-improvement are you currently or have you previously tried (yoga, therapy, meditation, another coach, etc.)? *
Why do you believe I can potentially help you? *
How committed are you to your self-development at this point in time? *
I'm not ready for change.
I want to see a powerful transformation and I'm ready to put in the work!
How did you hear about me and my coaching/yoga services? *
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