One-on-One Coaching Request
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Full name
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SKYPE Name or Phone Number
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Please fill out this form to the best of your ability (write as much as you desire!)
How would you describe the state of your current health now?
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What is it you are wanting to achieve in the next 3 months?
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What are 2-3 areas affected by not having your ideal health?
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Why do you want to change your current state of health?
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What does your optimal health look like?
How will you feel? What will you do?
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What has been your biggest challenge?
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What has worked for you in the past? Why do you think it worked?
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What hasn’t worked for you in the past? Why do you think it didn’t work?
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What do you typically eat throughout the day? Include breakfast, lunch, dinner, snacks, and drinks.
What foods would you like to eat LESS of? Why?
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How much water do you drink per day?
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List any physical activity
Frequency and duration
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Now, let’s get to the nitty gritty. Tell me about your digestion.
How often do you have bowel movements? Are they pleasant? Do you experience any bloating/gas? The more you share, the better.
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What motivates you?
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What demotivates you?
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List your main concerns or goals which have prompted you to seek out health coaching.
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What do you need the most help with right now? *
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How did you find out about my program? *
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Please list any other additional information you would like for me to know :)
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