Core Wellness Institute Private Coaching Application

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Thanks for completing the following application.

If you are accepted, you will receive a link to enrollment details.

Participants will then be accepted on a first come, first serve basis.

Also, completing this form does not obligate you to anything.

Thanks and hope to talk to you soon,

Dr. H

What words describe the feelings you have now about your current state of health? (apathy-happiness-anxiety-sadness–embarrassment-anger-Etc.) Why? *

Please describe how you desire to feel? *

What are the main reasons why you are committed to improving your state of health? *

What specific health issues are affecting your quality of life? *

(Name them in order of importance to you)

What is it about this approach that makes you feel like I can help you? *

What are your top 2 specific health improvement goals over the next 8 weeks? *

What is your level of willingness to make changes in your current lifestyle habits towards health? (0% = I’ll never change, 100% = I’ll do anything that makes sense to me!) *

I understand this coaching relationship is NOT a doctor / patient relationship and I agree to discuss any exercise or nutrition recommendations with my doctor. *

I understand and agree

I don't understand and don't agree

Required

Can you effectively use Skype or can you learn before we meet?

YES

Can you get up and down off the floor without assistance?

Yes

Your Name (First and Last) *

What is your primary email address? *

Your location (and time zone if you know it) *

Best phone # to reach you *

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