Empower Nutrition Client Intake Form
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Email *
The consult and content provided is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition or your health. Never disregard professional medical advice or delay in seeking it because of something you have read or heard on my platforms. *
First and Last Name *
Which coaching service are you interested in? *
Phone Number *
Birthday *
Height *
Weight *
What are your current struggles with nutrition and fitness? Do you have a goal weight? *
What is your history with nutrition and fitness? Please be as detailed as possible. *
What is holding you back from hitting your goals? Give yourself time to think on this one - I don’t know is not an acceptable answer. *
How long have you been following/targeting your current calories or set of macros? Please share them below: *
What are your goals? Please include specifics surrounding weight, measurements, performance, health, aesthetic, strength, endurance, etc. *
I utilize WhatsApp, MarcoPolo, Instagram and MyFitnessPal as tools for connection and food awareness. Please share your profiles name where applicable so I can connect with you. *
Please share any current conditions, heath history or emotional triggers that may be relevant to our goal setting and process. *
Please let me know your Time Zone: *
There will be a $25 charge for any abandoned appointments or unanswered calls, as I take time in preparing for each individual session. I am more than happy to make arrangements to reschedule or reimburse fully with 24 hours notice. Thank you for your understanding. *
A copy of your responses will be emailed to the address you provided.
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