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1-on-1 Remote Coaching Client Application
Welcome to the Insight Nutrition client application. By filling out this application, answering each question in detail will allow us to build a more personalized and efficient program. Once you have completed the application process we will follow up with a phone or video call to discuss your answers and how they will shape your journey towards a healthier, happier, and more sustainable lifestyle.
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* Required
Email
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Your email
Let's start with your name
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Your answer
Date Of Birth
MM
/
DD
/
YYYY
Gender
Male
Female
Other:
Clear selection
Tell me more about yourself. By learning more about your lifestyle and your habits, I can take better care of you and make sure coaching is a good fit for you and your goals.
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Your answer
Email
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Your answer
Phone Number
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Your answer
How do you prefer me to contact you?
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Email
Phone
Skype or other video chat
Text
Other:
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Fat Loss - look good, feel great by establishing habits that will not only get you the results you seek, but will help maintain them.
Minimalist - a basic approach to healthy food and lifestyle changes. This is not particularly focused on fat loss, however, depending on how consistent you are with these habits fat loss could be one of many positive results.
Performance - nutrition can be a game changer when it comes to improving strength, physical fitness, and/or performance in your sport. Although bodyweight can impact performance, this program does not prioritize weight loss.
Other:
Why do you want to accomplish this goal?
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Your answer
On a scale from 1-5, how important is achieving this goal for you?
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Not important at all, I'm happy where I'm at
1
2
3
4
5
Life Changing, I would have more confidence and happiness than ever!
How long have you been trying to achieve this goal?
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Your answer
How will achieving this goal make a positive impact on you and the people you care about?
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Your answer
What's prevented you from achieving your goal?
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Your answer
Approximately how many hours per week do you exercise?
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Fewer than 5 hours
5-9
10-14
15-19
20+
What type of job do you work? Does your job involve sitting for 6+ hours a day?
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Your answer
Are there any other people (besides yourself) that depend on you being healthy? Please list all that apply
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Spouse or Significant Other
Child(ren)
Pets
Career
Other:
Required
Have you been diagnosed (currently or in the past) with any significant medical condition(s)
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Yes
No
Right now, do you have any specific health concerns, such as illnesses, pain, and/or injuries?
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Yes
No
On a scale of 1-10, how would you rank your health right now?
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Worst
1
2
3
4
5
6
7
8
9
10
Awesome
On a scale of 1-10, how do you feel about your schedule, time us, and overall busy-ness?
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My life is panicked and insane
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2
3
4
5
6
7
8
9
10
My life is perfectly calm and relaxed
Think about all the activities you're involved in (e.g. work, school, caregiving, housework, travel, etc.). Then assess as best you can. Given all the demands of your life, what is your typical stress level on an average day?
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No Stress
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2
3
4
5
6
7
8
9
10
Extreme Stress
On average, how many hours per night do you sleep?
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4 or fewer hours
5 hours
6 hours
7 hours
8 hours
9 hours
10 or more hours
How READY are you to change your behaviors and habits?
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Not at all
1
2
3
4
5
6
7
8
9
10
Completely
How WILLING are you to change your behaviors and habits?
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Not at all
1
2
3
4
5
6
7
8
9
10
I'll do whatever it takes!
There are no quick fixes, magic pills, powders, etc. that will provide the changes you desire? Patience, consistency, and ownership is the only way to obtain sustainable results. Do you agree?
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Yes
No
Before and after photos are a great way for me to showcase the success of my clients, but I want to make sure that you are totally cool with me sharing yours. Do you consent to me using before and after progress photos of you for advertisement? For privacy reasons, I will always make sure your face is not visible.
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Yes
No
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