Please answer the questions below in as much detail as possible. This will allow me to gain a better understanding of your top priorities, goals and concerns. Upon submitting, I will be in touch regarding next steps. Thank you, and congratulations on taking this important step towards being your most confident and joyful self!

Name

First Name

Last Name

Phone Number

Email Address

Date of Birth

YYYY

How did you hear about me?

Have you completed any of my past programs? If so, which one?

On a scale of 1 to 10, how would you rate your present fitness level (10 being the highest level of fitness possible)

What obstacles and challenges have you faced in the past that kept you from achieving your goals? Check all that apply.

Lack of Motivation

Lack of Time

Boredom

Health Issues/Injury

Money

What are you hoping to gain out of working with me? Think big picture goals here!

How can I help to motivate you?

Have you had a personal trainer or health coach in the past? If so, what did you like and/or dislike about your training program and/or trainer?

If planning on enrolling in a Personal Training Program, where do you plan on completing your workouts?

Gym

Home

Combination of both gym and from home

How would your like to measure your progress?

Please check all that apply.

Exercise training log (this will be tracked on my end)

Using a scale to track weight (we can discuss the frequency of weigh-ins if this is something you'd like to track)

Body measurements

Progress Photos

I'd prefer not to track my progress yet

On average, how many hours of sleep do you get per night?

Are you on any medications I should be aware of? If so, please list them.

How would you rate your quality of sleep?

How would you rate your stress level?

What are some ways you cope with stress? (Meditation, yoga, breathing, eating, going for a walk, gardening, playing piano, exercising, etc.) Please list.

Do you have any health conditions I should be aware of? If so, please list them in detail.

Do you have any injuries or physical limitations? If so, please list them in detail.

What are you currently doing to heal your past relationship with diet and fitness culture?

Diet and fitness culture include any past experiences that have led to feelings of stress and anxiety around food, fitness and health-related topics.

Are you happy with your body? Please explain your answer

What positive things have you already implemented that align with your health, fitness, and/or wellness goals?

What are your biggest challenges with your body image, eating habits and food right now

On a scale from 1 to 10, how open are you to trying new things (1 being "not ready at all," and 10 being "let's do this!"

HOORAY! Let's do this!

Thank you for taking the time to fill out this information. Remember, all of your answers will remain confidential. I will be in touch shortly with next steps and further details!

By submitting this form, I acknowledge that the I take full responsibility for my life and well being, as well as the lives and well being of the my family and all decisions made during and after this Program. I expressly assume the risks of the Health and Fitness Program, including the risks of making nutrition, lifestyle and fitness changes. I release the Coach and Personal Trainer from any and all liability, damages, causes of action, allegations, suits, sums of money, claims and demands whatsoever, in law or equity, which I ever had, now have or will have in the future against the Coach, arising from my past or future participation in, or otherwise with respect to, the Health and Fitness Program, unless arising from the gross negligence of the Coach. I, the Coach, will keep the Client's information private, and will not share the Client’s information to any third party. -Sally Willoughby

Signature

Thank you for your submission. I will be in touch shortly!

Let’s get to know one another!

What is your “Why?”

Thank you - you rock!

PROGRAMS

ABOUT

GET INVOLVED