Name *

First Name

Last Name

Phone *

(###)

###

####

Are you currently pregnant, lactating, post-pregnancy (within 1 year), or trying to conceive? *

Pregnant

Lactating

Post-Pregnancy

Trying to conceive

None of the above

What is your main goal? *

Lose weight

Build muscle

Body recomposition (lose fat/build muscle)

What are the main obstacles getting in the way of your goals? *

Not sure of what to eat

Not sure of how much to eat

Lack of meal planning/meal prep

Not enough time to cook

Too much alcohol

Food cravings

Emotional eating/stress eating

Eating too quickly

Always hungry

Are you the primary caregiver for any children, individuals with disability or elderly relative? *

Children

Individuals with a disability

Elderly relative

None of the above

A key part of maintaining a healthy lifestyle is taking full responsibility of monitoring your needs. It's important that you understand: The advice of your coach cannot replace the advice of a trained medical doctor. It's your responsibility to work directly with your physician before, during, and after seeking coaching. If you choose to be coached without the prior consent of your physician, you agree to accept full responsibility for your decisions and to hold me harmless from any liability with respect to injury to you or your property arising out of or connected with your use of the information discussed. *

I consent to this medical release