Consultation Form
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.
First name
Your answer
Last name
Your answer
Email address
Your answer
Phone number
Format: 704-999-0987
Your answer
Age
Marital Status
Race
Sex
Are you currently...? (select all that apply)
Required
Best way to contact you (note: the consultation is conducted through a conference line)
Time Zone
Current weight/size
Your answer
Current height
Your answer
Desired weight and/or size
Your answer
Why do you want to work with accountability coach and how can an accountability coach best help you?
Your answer
What 3 goals do you want to achieve within the next 3 months?
Your answer
What do you struggle with the most? (select all that apply)
Required
If things were better with your eating/exercise, what would be different?
Your answer
What have you already tried? What worked/didn't work?
Your answer
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?
Your answer
If you are on medication(s), lists some of the side effects.
Your answer
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)
Your answer
Date
MM
/
DD
/
YYYY
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Additional Terms