First Name *

Last Name *

Birthday *

Where exactly were you born? City, State, Country *

The exact time you were born. If you don't know, estimate. *

Email *

Phone *

Why did you reach out to me to help with your fitness? *

Where do you want your relationship with your body to be in 6-12 months? *

What are your biggest goals and why? (Be specific) *

What is preventing you from reaching these goals? *

Do you currently track your nutrition? *

How often do you exercise? *

Do you suffer from any of the following: *

Does my approach sound right for you? My program is based on helping you get fit, athletic, and heal from pain - mental, emotional & physical. We’ll focus on releasing unresolved traumas in your emotional body, creating new habits in your mental body, and create a strong, flexible, and fit physical body. *

Are you willing to invest in long term change? I will provide a clear plan of action to help you reach your goals, however, it may take a few months to get there. *

Are you willing to commit or decline my service when I call? *

When day(s) are you available for my phone call? *

What Time Zone do you live in? *

When is the best time to call you? *

Please add any additional information you feel is important for me to know. *