Health & Fitness Program Application
Help me get to know a little about you and your goals!
Email address *
Phone *
Name: (first and last) *
Today's Date *
When is your birthday? *
How did you find me? *
if you knew you would not fail, where would you ideally like to see yourself in 3 months? Think physically, emotionally, mentally, life goals, etc. *
Are you willing to invest in a fitness and nutrition program so that I may coach you towards achieve your goals? *
What are your health & fitness struggles currently? Please be specific. (Address digestive health, energy level, any weight loss/gain goals, hormonal balance, pain, inflammation, etc) The more details the better. *
Please rate your energy level. *
You can barely get out of bed
You don't drink any stimulants and have vibrant energy all day
Please rate your digestive health. 1- Poor 10- Flawless! *
Please rate your stress level *
Unbearable. Constantly stressed
You're on a beach relaxed
Please rate your quality of sleep *
HORRIBLE. I get 3-5 hours of sleep/night
Amazing! I sleep like a baby 8+ hours each night
Please rate your level of confidence in yourself and your ability to be successful. *
I don't believe I'll ever be successful
I KNOW I will be as successful as I want to be. I feel it in my bones!
What are your biggest barriers to reaching your goals right now? Why have you not been successful in the past? *
Give me a glimpse into your nutritional habits. What do you eat normally? Have you ever struggled with being an emotional/stress eater? Are you a chronic dieter? Do you feel guilty when you splurge? Do you have good self control when it comes to junk food/sweets? Any specific cravings? *
Which Nutritional approach do you feel you'd benefit from more? *
Do you currently have any food sensitivities? Do you have a plan or guide for your nutrition that you follow? *
What is your current fitness level-- beginner, intermediate or advanced? *
Would you be interested in doing a 3-Day Cleanse to jump start your metabolism and help banish belly bloat? *
Please check which fitness equipment you have at home *
Are you interested in Energize (Plant based pre-workout/energy booster) *
Are you interested in Recover (BCAA's formula to reduce muscle soreness and improve muscle building) *
Are you interested in Bevvy? ( *
Are you interested in Beachbars? (Our clean-eating Protein snack bars)
Clear selection
Are you interested in Collagen scientifically proven to improve skin, nails + hair in just 30 days? *
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- Best for those with digestive sensitivities: Chocolate, vanilla, tropical strawberry, & cafe latte) *
Are you interested in a wholesale/coach 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!) *
Are you interested in joining our team of health coaches and building a business of your own? *This can be as part-time or full-time as you'd like. We have everything set up for you to help you be successful! Our team is in the top 5% of the company and was named a 2019 + 2020 Premiere team. We know how to make anyone successful whose willing to learn! *
Anything else you would like to add about your situation?
A copy of your responses will be emailed to the address you provided.
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