Strategy Session Questionnaire

Thank you for signing up for a FREE Strategy Session!

Your FREE Strategy Session is a unique opportunity for you to talk with me about your health concerns and goals, any of my programs or services, and how I may be able to help you. This conversation is all about YOU!

During your session, we will talk about where you are now, and what your health goals are, and what obstacles are getting in the way of your success. Based on the information you provide, I will do an assessment of your current situation and make recommendations as to how I can help you get to where you want to be as fast as possible.

NEXT STEP:

In order for you get the most out our chat together, please take the time to fill out the questionnaire below to the best of your ability. It is a preliminary tool I use to help me learn a little bit more about you and your needs before our session. Once you click "submit" your information will be delivered directly to me so I can review it. Then, I will contact you (usually within 24 hours) to set up an appointment for our session.

Strategy Session Questionnaire

I respect your privacy! Please be assured that all of your information will remain confidential.

Personal Information:

* Indicates required field

Name: *

First

Last

Home Phone: *

Mobile Phone: *

Email: *

Birthdate (YYYY/MM/DD) *

Age: *

Height: *

Current Weight: *

Weight Six Months Ago: *

Weight One Year Ago: *

Desired Weight: *

What city do you currently live in? *

Number of Children: *

Occupation: *

# Hours per week: *

Stress level at work (0-10) *

Please list your 3 main health concerns: *

Other goals/concerns: *

Do you have any digestive issues? *

Allergies or sensitivities? *

At what point in your life did you feel best?: *

Any serious illnesses/hospitalizations/injuries?: *

Reaching or approaching menopause? *

Any menopausal symptoms? *

Are your periods regular? *

How frequent? *

How many days is your flow? *

How is your sleep? *

How many hours per night? *

Do you wake up at night? If so, why? *

Any healers, helpers or therapies with which you are involved? Please list: *

Do you take any supplements or medications? Please list: *

What role do sports and exercise play in your life?: *

What do you typically eat for breakfast? *

What do you typically eat for lunch? *

What do you typically eat for snacks/drinks? *

What do you typically eat for dinner? *

Do you cook? If so, what percentage of your meals are home-cooked? *

Are you happy with your current diet/lifestyle? *

How is your current health or weight negatively affecting you? *

Are you willing to make food and/or lifestyle changes in order to reach your goals? *

What is preventing you from reaching your health or weight goals? *

Will family and/or friends be supportive of your desire to make food and/or lifestyle changes?: *

Would you feel more confident reaching your goals if you had personalized coaching support and guidance, or would you prefer a Do-It-Yourself approach? *

What are you hoping to achieve from our session together? *

Is there anything else you'd like to share? *

Submit

Thank you for signing up for a FREE Strategy Session!

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Strategy Session Questionnaire

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Thank you for signing up for a FREE Strategy Session!

NEXT STEP:

Strategy Session Questionnaire

Personal Information:

Join my mailing listFREE STRATEGY SESSIONACCREDITATION & AFFILIATESTERMS & CONDITIONS

FOLLOW ME ON SOCIAL MEDIA

Join my mailing list

FREE STRATEGY SESSION

ACCREDITATION & AFFILIATES

TERMS & CONDITIONS