Full Name
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Email
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1. What’s your biggest health challenge right now?
2. How long has this been an issue for you?
Other (please specify)
4. What’s your primary goal in working with me?
5. Are you currently managing a chronic illness?
Yes
No
If Yes, Please Specify
7. Is there anything else I should know about your situation?
8. On a scale of 1-10, how committed are you to making real changes?
1 - I just want to learn more, not ready for big changes
3 - I'm unsure, and have questions
6 - I’m ready to start but need a lot of guidance
10 - I’m 100% committed to doing what it takes to take control of my health and wellbeing.
9. Are you willing and able to invest in private coaching at this time?
Yes, I’m ready to invest in my health
I need a little more info but I’m serious about making changes
Not right now, I’m looking for free resources
10. If we're a good fit, when would you like to start?
ASAP
Next Month
In 2-3 Months