First Name
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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
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
