Private Coaching Application
Please fill out the application below for the private coaching program.

This Client Assessment Form is a way for me to get to know you, your lifestyle and your specific goals as a client.
Please answer all questions as accurately as you can.


Before beginning your program, please visit your physician for standard blood work and a check-up in order to ensure that you have a clean bill of health.
This program is not intended to replace your physician’s recommendations and/or advice regarding decisions related to your health.

Email address *
Full Name *
Your answer
Email Address *
Your answer
Phone Number *
Your answer
Gender *
Age *
Your answer
What are 3 fitness goals? *
Your answer
What do you struggle with in terms to reaching these goals? *
Your answer
What are you doing currently (or what you have done) to improve this situation in the last 6 months. *
Your answer
On a scale from 1-5 (1 being not important and 5 being urgent), how important is to you to overcome your struggles and achieve your goals? *
Your answer
What are your nutrition goals? (check all that apply) *
Do you feel like food controls you? If you were to go to a party and your favorite dessert was there, but it didn't fit your day, could you resist? *
What physical shape are you in? *
How comfortable to you feel in shorts? *
How comfortable do you feel in tank tops? *
How comfortable do you feel in a swim suit *
If we were to work together, what would be your ideal outcome/resolution? *
Your answer
Have you ever worked with a coach before? If yes, how was your experience? *
Your answer
How committed are you to achieve your fitness goal? *
Investment: Are you willing to invest $1000 per month in order to get the right nutrition plan that is perfect for you, fit into your old jeans, gain more energy, trim inches off your waistline, burn stubborn fat, and have custom workouts that you love? *
A copy of your responses will be emailed to the address you provided.
Never submit passwords through Google Forms.
This form was created inside of Smofitness. Report Abuse - Terms of Service