First Name
*
Last Name
*
Phone
*
Email
*
Date of birth
*
Does your self-care include some form of connection with others or physical activity?
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Yes
No
Does your self-care include alcohol, chocolate and “treating yourself” with “naughty food”?
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Yes
No
Do you eat protein 3-5 times a day?
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Yes
No
Are you actively engaging in self-care activities every week?
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Yes
No
Here is a list of possible goals (tick all that apply):
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Lose fat
Gain weight
Maintain weight
Add muscle
Improve physical fitness
Look better
Feel better
Have more energy/vitality
Get control of eating habits
Get stronger
Create better balance
Feel less stressed
Love myself more
Sleep better
Something else
On a scale of 1 to 10, with 1 = not willing at all and 10 = extremely willing, how willing are you to significantly modify your diet?
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On a scale of 1 to 10, with 1 = not willing at all and 10 = extremely willing, how willing are you to engage in regular exercise/activity?
*
On a scale of 1 to 10, with 1 = not willing at all and 10 = extremely willing, how willing are you to practice relaxation techniques on a regular basis?
*
On a scale of 1 to 10, with 1 = not willing at all and 10 = extremely willing, how willing are you to improve your sleep habits?
*
Is anyone else involved in your decision-making regarding how you choose to improve your lifestyle
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Yes
No
Have you worked with a coach before?
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Yes
No
On a scale of 1-10, how do you rank your health right now? (where 1=Horrible and 10=Awesome)
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How many hours do you sleep each night, on average?
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Less than 5
5-7
7-9
9+
Do you wake up with any of the following:
Fatigue
Dry mouth
Headache
The feeling that you don't want to get up
Pain in your body
How much water do you drink each day?
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Less than 1L
1-2L
2-4L
More than 4L
I hate water and I prefer to drink other stuff
On a scale of 1 to 10, with 1 = chilled and 10 = very stressed, how would you rate your stress levels?
*
What are your vices? Choose all that apply:
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Chocolate
Chips/crisps
Alcohol
Fast food/Takeaway
Sugary beverages
Caffeine
Other
None
Are you prepared to invest time and money in yourself to improve your daily habits, simplify your routine and rediscover your happiness, health and vitality?
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Yes
No
Do you run a business?
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Yes
No
Are you a Personal Trainer wanting to learn more about healthy habits so you can help your clients more effectively navigate towards their goals?
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Yes
No
Are you prepared to invest:
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$29-$39week? – we can focus on Eating, Breathing or Hydration
$49-$99/week? – we can focus on Eating, Breathing, Hydration, Sleep or Movement
$99-$199/week? - we can focus on Eating, Breathing, Hydration, Sleep or Movement
$200-$500/week (normally tax deductible if you run your own business)? - we can focus on absolutely everything that is keeping you stuck and customise your program to suit your busy schedule
I can’t afford this right now
Complete Quiz
