Name
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First Name
Last Name
Phone
*
(###)
###
####
Your age
*
Your occupation?
*
Have you ever worked with a coach/trainer in-person or online before?
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If yes to the question above, please tell me why you no longer work with them and what you liked and disliked about working with them?
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What are some things you have ENJOYED the most about any exercise/training you have done in the past?
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What are some things you have DISLIKED the most about any exercise/training you have done in the past?
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What do you value MOST in hiring a coach/trainer? Please choose 2.
*
If other, please elaborate.
What do you want to get out of this program? Please check all that apply.
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If other, please elaborate.
If you were to consider making changes to your habits, your health, your eating, and / or your body, what might they be?
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Until now, what has blocked or held you back from changing these things?
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Right now, how much do the people around you support health, fitness, and / or behavior change?
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Not at all
Occasionally
Completely
Right now, how do you feel about your schedule, time use, and overall busy-ness?
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Calm and relaxed
Well balanced
Hectic and stressful
Right now, how READY are you to change your behaviors and habits?
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Not at all
Unsure
Completely ready
Right now, how WILLING are you to change your behaviors and habits?
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Not at all
Unsure
Completely willing
Right now, how ABLE are you to change your behaviors and habits?
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Not at all
Unsure
Completely able
What are you prepared to do to work towards and achieve your goals?
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Is there anything else you’d like to share?
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Which service are you most interested in?
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builtXyou™ Transformation Program
1-on-1 Training/Nutrition Coaching
I'm not sure
