Nutritional Coaching Program

Full Name

First NameLast Name

Email

example@example.com

Gender

Date of Birth

MonthDayYear

Age

years

Height

ft/In

Weight

lbs

What do you do for a living?

Please list if you are a current student or athlete

How would you describe your current activity level?

Please list the physical activities that you participate in outside of the gym, work, or school:

Do you follow a regular working schedule, do you work days, afternoon or nights?

How often do you travel?

If you have any diagnosed health problems list the condition(s).

If you are on any medications, please list them.

What additional therapies are being undertaken for the given health problem(s)?

If you have any injuries, please list them.

What additional therapies are being undertaken for the given injury?

Are you experiencing any stresses or motivational problems?

Has anyone of your immediate family developed heart disease before the age of 60?

Do any diseases run in your family?

Do you suffer from diabetes, asthma, high or low blood pressure?

Please list:

Are you a current cigarette smoker?

Your current diet could be best characterized as:

Please rate your readiness for change.

What following goals does best fit in with your goals?

What is your long-term goal with your training?

What is your goal body-weight, within your chosen time-frame?

TImeline for achieving your goal.

Rows	8 WKS	12 WKS	16 WKS
NOW

How often are you willing to train a week to reach your goal?

Please rate your motivational level to do what it takes for reach your goal.

Are you currently excersising regulary (at least 3x per week)?

Have you worked with a nutrition coach before?

At what times during the day would you prefer to meet with a coach?

How often do you want to do individual coaching each week? (if in-person)

Please Choose

What are your expectations on me as your Nutrition Coach?

Coaching Programs

8-Week In-Person Program

8-Week Tailored program for weight loss or to gain lean muscle. This will include a food log, custom grocery list, custom supplement guide, and weekly educational check-ins with a coach. Check-ins are 30 minutes each.

$440.00 Quantity

12-Week Online Program

12-Week Tailored program for weight loss or to gain lean muscle. This will include a food log, custom grocery list, custom supplement guide, and specific information to needed to have a successful program.

$200.00 Quantity

12-Week In-Person Program

12-Week Tailored program for weight loss or to gain lean muscle. This will include a food log, custom grocery list, custom supplement guide, and weekly educational check-ins with a coach. Check-ins are 30 minutes each.

$600.00 Quantity

16-Week Online Program

16-Week Tailored program for weight loss or to gain lean muscle. This will include a food log, custom grocery list, custom supplement guide, and specific information to needed to have a successful program.

$250.00 Quantity

16-Week In-Person Program

16-Week Tailored program for weight loss or to gain lean muscle. This will include a food log, custom grocery list, custom supplement guide, and educational check-in sessions with a coach. Check-ins are 30 minutes each.

$720.00 Quantity

Total

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

1.) CANCELLATIONS

Cancellations should be made at least 24 hours in advance of a scheduled session. Sessions cancelled less than 24 hours in advance will be charged in full to the client.

2.) LATE ARRIVALS

Each session shall be 30 minutes in length. Sessions will not be extended (unless time is available) due to the lateness of the client or due to interruptions caused by the client.

3.) ALL THE INFORMATION I HAVE GIVEN IS CORRECT

All the information on this form is correct and to the best of my knowledge. I have sought and followed any necessary medical advice. I understand that all the information given will be kept confidential.

I AGREE TO THE ABOVE TERMS & CONDITIONS!

Upon completion of payment, you will receive your program via email. It will be in PDF format, so you will be able to download it if necessary. If you purchased an in-person program, please wait for your coach to reach out to you to set up check-in sessions and any other program materials.