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.
Sign in to Google to save your progress. Learn more
Email *
Let's start with your name *
Date Of Birth
MM
/
DD
/
YYYY
Gender
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. *
Email *
Phone Number *
How do you prefer me to contact you? *
*
Why do you want to accomplish this goal? *
On a scale from 1-5, how important is achieving this goal for you? *
Not important at all, I'm happy where I'm at
Life Changing, I would have more confidence and happiness than ever!
How long have you been trying to achieve this goal? *
How will achieving this goal make a positive impact on you and the people you care about? *
What's prevented you from achieving your goal? *
Approximately how many hours per week do you exercise? *
What type of job do you work? Does your job involve sitting for 6+ hours a day? *
Are there any other people (besides yourself) that depend on you being healthy? Please list all that apply *
Required
Have you been diagnosed (currently or in the past) with any significant medical condition(s) *
Right now, do you have any specific health concerns, such as illnesses, pain, and/or injuries? *
On a scale of 1-10, how would you rank your health right now? *
Worst
Awesome
On a scale of 1-10, how do you feel about your schedule, time us, and overall busy-ness? *
My life is panicked and insane
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? *
No Stress
Extreme Stress
On average, how many hours per night do you sleep? *
How READY are you to change your behaviors and habits? *
Not at all
Completely
How WILLING are you to change your behaviors and habits? *
Not at all
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? *
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. *
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy