Program Application Please give yourself a few quiet moments to sit and answer the following questions with honesty and clarity. Name *Phone *Email Address *Facebook ProfileInstagram User NameWhat is your current health status? *On a scale of 1-10 (1 being not at all ready, 10 being let’s do this!) how ready are you to nourish, move and rest your body in a very intentional, loving and positive way? *Please select an option12345678910Does your current body and health feel in alignment to your health vision? *Please rate your current readiness to change, on a scale of 1-10 (1 being not ready, 10 being very motivated to change): *Please select an option12345678910What are 3 words to describe the way you wish to feel? *What do you feel is stopping you from creating the health and wellness you crave? Barriers, habits, mindset, etc. *What is it costing you in your life by not getting “there”? *What are 3 words you would love to burn and walk away from? *In the past, what have you tried (techniques, diets, behaviors, etc.) to reach your health goals: *How would you describe your support system? *What do you do for a living? *What is your weekly schedule? How flexible is it? *Please list the physical activities you are involved in, including fitness/yoga routine, sports/leisure, other forms of movement: *Please list any health/medical conditions, previous injuries or current limitations: *Who prepares the majority of your meals? *Who shops for food? *Where do you shop for food? *What percent of the foods you eat are... whole _______% processed_______% take out/restaurants________% *How much time do you spend cooking/preparing meals each day? *Please list any food preferences, allergies, sensitivities/intolerances: * Please list current medications (and their purpose) and supplements you currently take: * On a scale of 1-10 (1 being not at all, 10 being very open to being coached), how coachable are you? *Please select an option12345678910How can I best support you in your goals? *How can I best support you in your goals? *At the half way point in our program, I will check in with you. If you are struggling with consistency, commitment, making small daily action steps, what will help you get reengaged in the process? *Age *Current Approximate Weight *Height in inchesSend MessagePlease do not fill in this field.