The accountability coach consultation form includes questions to help us understand fully your needs, goals, lifestyle, personality, attitudes toward health and fitness, and reasons motivating you to seek out an accountability coach.
20-29 years old
30-39 years old
40-49 years old
50-59 years old
60-69 years old
Black or African American
Hispanic or Latino
Native American or American Indian
Are you currently...? (select all that apply)
Out of work and currently looking for work
Out of work and NOT currently looking for work
Unable to work
Best way to contact you (note: the consultation is conducted through a conference line)
Desired weight and/or size
Why do you want to work with accountability coach and how can an accountability coach best help you?
What 3 goals do you want to achieve within the next 3 months?
What do you struggle with the most? (select all that apply)
Getting enough sleep
Not having enought time
No/lack of support
If things were better with your eating/exercise, what would be different?
What have you already tried? What worked/didn't work?
On a scale of 1-10, 10 being the highest, how confident are you that you could change your lifestyle?
Why did you choose the number above?
If you are on medication(s), lists some of the side effects.
Which of the following are you in the process of changing or plan to change in the near future?
How to Schedule Your Free 30 Minute Consultation
After you submit your form, you will be taken to a screen with a link to schedule your appointment. We look forward to working with you and helping you to reach your goals.
Your Signature (digital)
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