Client Initial Intake Form

Welcome to Elevation Performance and Wellness!

My name is Lia and I'm a Western Masters Graduate and personal trainer. I have experience with clients of all ages, especially older populations.

My goal is to restore your health, prevent injuries, and foster lifelong habits that enable you to pursue your passions and keep you doing what you love, longer!

We will do this by focusing on creating lasting habits, establishing foundational exercises, and creating a customized plan just for YOU!

After you fill out the form below, we'll hop on a quick phone call to discuss your goals and get you on the path to achieving them!

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Email *
Name *
Address
Phone number
Date of birth?
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DD
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What is your overall goal/goals? Be specific!
What have you done on your own to try and achieve those goals? *
What do you think is holding you back or limiting you from achieving those goals? *
How has not achieving these goals impacted your life? Physically, mentally, and emotionally? *
What would change in your life if those goals are met? How would that make you feel; physically, emotionally, and mentally? *
On a scale from 1-10 how important is are reaching these goals for you? 10 being extremely important, 1 being not as all. *
On a scale from 1-10 how confident are you in reaching these goals on your own? 1=not confident, 10= very
 *
What can I do to help you achieve those goals? *
Do you have any exercise equipment at home? Free weights? Or do you have access to a gym?  *
What are your current exercise habits? *
Are there any exercises you CANNOT do/ absolutely hate? *
Anything else you want me to know? *
A copy of your responses will be emailed to the address you provided.
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