Name
*
First Name
Last Name
Email
*
Phone
(###)
###
####
Location (City, State, Country)
*
Occupation
1. What are your primary health and wellness goals?
2. What areas are you currently struggling with?
3. How would you describe your current eating habits?
4. What’s your current fitness routine?
5. Have you worked with a coach before?
Yes
No
6. Which coaching tier are you most interested in?
Tier 1: Nutrition Coaching (Focus on personalized meal planning, nutritional guidance, and habit-building)
Tier 2: Wellness Coaching (Focus on holistic health: nutrition, fitness, and mindset coaching)
1. Do you have any current or past medical conditions that may affect your wellness journey?
*
2. Are you currently taking any medications or supplements?
*
3. Do you have any allergies or dietary restrictions (e.g., gluten-free, vegan)?
*
1. How would you rate your current stress levels?
Low
Moderate
High
2. Do you practice any mindfulness or relaxation techniques (e.g., meditation, journaling, yoga)?
Yes
No
3. What is your current sleep routine?
Consistent & Restful
Somewhat Consistent, Could Improve
Poor, Irregular Sleep Patterns
4. What motivates you to improve your health and wellness?
1. Why are you seeking nutrition or wellness coaching at this time?
*
2. What do you hope to achieve by working with Spirited Core Wellness?
3. Are there any specific goals or milestones you’d like to reach in the next 3-6 months?
4. Are you ready to commit to making changes in your nutrition and/or wellness?
Yes
No
Not Sure Yet
5. How many hours per week can you dedicate to coaching, fitness, and meal prep?
Is there anything else you would like us to know about your goals, lifestyle, or preferences?
