Weight Loss Coaching – Application

Name*

First Last

Age*

Email Address*

Phone Number*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

What do you do for a living?*

Why are you seeking a personal Dietitian Coach?*

Have you ever met with a Registered Dietitian?*

How was that experience for you?*

On a scale of 1-10 (10 being the most dissatisfied), how dissatisfied are you with your health?*

Did something trigger a change in your health?*

If you had a magic wand and could erase three problems, what would they be?*

How committed are you to make changes to erase those problems? (10 being the most committed)*

Have you ever made any changes in your eating habits?*

Please elaborate in a sentence or two.*

Are you willing to take supplements?*

How did you hear about us?*

How much would you say you have spent on your health (including diet programs, surgeries, lab work, etc.) in the last 3 years?*

Have you made other major investments in yourself in the last 3 years?*

Are you in the middle of any other coaching program? If yes, which coaching program? Please share how you feel about additional support.*

If you’re accepted into this program, what top 3 things do you want to accomplish?*

How will your life, health, career and/or relationships be different if you are accepted into this program?*

Are you willing to make a significant (or even a “stretch”) financial investment? Feel free to elaborate.*

What else should I know about you? 🙂*

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