Coaching Application Form

Hello there! As a dietitian nutrition coach, I specialize in helping people lose weight, keep it off and “Go the Distance” with their health. I focus on individual behavior-based weight loss coaching and help people to understand that changing their habits and lifestyle is the secret to long term success with their weight. Please answer the questions below so I can better judge if you are a good fit for my program. If I feel you are a good fit, we could schedule a discovery call to discuss the program more. Thanks so much!

Name *

First

Last

Email *

Please enter your email, so we can follow up with you.

What made you reach out to me for help in losing weight and getting healthy? *

What are the major goals you would like to work towards right now (be as specific as possible)? *

Rate the importance of achieving these goals within the next 3-6 months (1 being not important and 10 being very important and committing 110%).

Selected Value: 1

What challenges or obstacles are standing in the way of you achieving these goals? *

What happens if you did not achieve these goals? How would it impact you? What happens if you did achieve these goals? How would your life improve for the better? *

If we worked together for the next 3-6 months, what would need to happen in order for you to be thrilled with your results (be as specific as possible)? *

Are you willing to commit to weighing yourself on a consistent basis and keeping a daily food journal? Are you also willing to commit to consuming more fruit and vegetables, along with making more time for physical activity? *

At this time, are you willing to invest yourself emotionally and financially in the way of nutrition coaching? Please explain the reasoning behind your response. *