Health & Fitness Program Application

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Help me get to know a little about you and your goals!

Email *

Name: (first and last) *

Phone *

Today's Date *

YYYY

How did you find me? *

What are your 3 biggest struggles currently in your wellness journey?
*

What are your top 3 goals you want to establish for these next 30 days? List a goal from each of the 3 categories. Please share as much detail as possible. Examples are only shared as examples, it could be whatever is the highest priority for you.

1- Physical goal: (Ex: weight loss goal, strength goal, size, toning, improve digestion, etc)

2- Mental/Emotional goal: (Ex:reduce anxiety, improve motivation, improve depression, improved stress management, etc)

3- Functional Goal: (Ex:Meal prep, have a solid morning routine, time management, etc...)

Why are the above goals important to you? What is the cost if you don't make a change?
*

Which Nutritional approach do you feel you'd benefit from more? *

A program with more structure. You'd be told exactly how many portions of each food group to eat every day based on your goals and starting point. It would include training on the reasons why we crave certain foods, why we use the macronutrient breakdown we do and why portion control is important to be successful in your goals.

A program with more flexibility. With this approach, you could make it work even while traveling or eating at restaurants because you'll learn how to plate each meal. There are no food lists or counting involved. It is created especially for those who have a negative relationship with food such as emotional eating, stress eating, chronic dieters, or those who starve & binge. It's a shift in mindset more than anything. You'd learn how to say YES to the right foods instead of focusing on saying no to the wrong foods.

I'm not sure

Do you have any digestive sensitivities and/or food intolerance's to dairy, gluten, etc?
*

Please check which fitness equipment you have at home *

Dumbells

Aerobics step

Pull Up bar

Exercise bands

Yoga Mat

Required

The following questions are about supplements and products that may benefit you.

I usually recommend my clients' start with a powerful foundational supplement called Shakeology. It is an incredibly nutrient dense formula that supports the body in several capacities with over 70 superfoods per serving. What flavor of Shakeology would you like to try first? (Flavors are Vanilla, chocolate, strawberry, cafe latte -OR- Vegan flavors- Chocolate, vanilla, cookies & creamy, tropical strawberry, & cafe latte) *

Would you be interested in doing a 3-Day Cleanse to jump start your metabolism and help banish belly bloat? *

Yes

Maybe

Are you interested in my "Morning Muscle Margarita" concoction to boost motivation + energy? (Consists of Energize, collagen, + Hydrate)
*

Yes- Lemon

Yes- Fruit Punch

Yes- Mixed Berry

Yes- Strawberry Lemonade

Maybe

Are you interested in Recover (BCAA's formula to reduce muscle soreness and improve muscle building) *

Yes- Chocolate

Yes- Orange Creamsicle

Yes- Chocolate Vegan

Maybe

Are you interested in Beachbars? (Our clean-eating Protein snack bars, certified GF, Vegan oprtion, low glycemic-index, good fiber source, all clean ingredients)

Yes- Chocolate Peanutbutter

Yes- Chocolate Cherry Almond

Yes- VEGAN Chocolate Almond Crunch

Maybe

Clear selection

Are you interested in First Thing? It is a morning health shot with 4 formulas combined in one to support brain function, immune health, energy, and stress support.
*

Yes

Maybe

Are you interested in a sleep support supplement called Last Thing?

Yes

Maybe

Clear selection

Are you interested in a preferred customer membership? (You can register for FREE to get all your supplements/goods at wholesale cost with a $15.95 monthly membership fee. Think Costco! Big savings!) *

Yes

Maybe

Are you or your spouse active duty military or veteran? *

Yes

Are you interested in learning more about becoming a coach yourself or joining our team ambassador program? *

Yes

Maybe

Anything else you would like to add about your situation?

A copy of your responses will be emailed to the address you provided.

Submit

Clear form

Never submit passwords through Google Forms.

reCAPTCHA

Privacy Terms

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms