Healthy Heather | New Client

About You

* Indicates required field

Name *

First

Last

Email *

Phone Number *

Is it okay to text this number? *

Yes No

Address *

Line 1

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City

State

Zip Code

Country

Your Current Health

How would you rate your overall physical health? *

Excellent Good Fair Poor

Is it okay to leave messages at this number? *

Yes No

How would you rate your quantity of sleep relative to the recommended 7-8 hours per night? *

Excellent Good Fair Poor

How would you rate the quality of your sleep? *

Excellent Good Fair Poor

Do you currently exercise? *

Yes No

What best describes the overall amount and intensity of your physical activity during the past three months? *

Exercise at least 5x/week for performance or competitive purposes Exercise 3 x/week in challenging workouts Participate in recreational sports 2-3 x/week, modest effort No scheduled or structured workouts in place

What best describes your current nutrition habits? *

I eat a balanced diet and feel good about my habits. I do okay most of the time, but lose it on the weekends. I know what I need to do, but can't make it happen I don't even know where to start.

Your Interests and Motivations

What do you do when you are not working (hobbies, sports, etc.) *

What do you do for fun? *

When you treat yourself, what are things you like to do? *

What is your idea of a great vacation? *

What influenced your decision to work with a coach? *

Have you ever worked with a coach before? If so, please describe your experience. *

What part of your life is working well right now? *

What part of your life could be working better? *

What are some obstacles that often keep you from reaching your goals? *

What motivates you to persevere and work hard? *

What would you do if success was guaranteed? *

What is the success you would like to achieve with a Wellness Coach? *

What are your best strengths? *

Your Goals

I am most excited to start changing... *

This is important to me because... *

I'll know I have achieved it when... *

I haven't achieved it yet because... *

I most need a coach's help with... *

Thank you! Please click SUBMIT and I will be in touch ASAP to schedule our first session!