New Client Intake Form

Thank you for selecting The Fabulous Fit Squad to help you achieve your weight loss and overall health goals. Step 1 is to complete the form. All fields are required.

Name *

Phone *

Email Address *

Birthday *

Height

Weight

What areas do you want to address with coaching *

Improve well being (health and happiness)

Improve energy

Increase physical activity

Mantain or manage current weight

Improve eating habits

Improve sleep

Manage stress

What's the one thing do you want more of in your life right now? *

What's the one thing do you want less of in your life right now? *

Listed below are some typical results experienced by coaching clients. Which 3 are most important to you? (direction, focus, accountability, a new perspective, fitness and nutrition strategies, motivation, new challenges, other-please list) *

How much time do you have to workout?

How many days/week can you workout?

Where do you workout?

Gym

Home

Other

If you workout at home, please list what equipment you have

On average, how much sleep do you each night?

less than 6 hours

6-7 hours

8+hours

I have trouble sleeping -- either getting to sleep or staying a sleep

Are you stressed?

1

2

3

4

5

1= stress what's that I'm as cool as a cucumber 5= I'm stressed I can't even describe it.

Do you have any medical condidtions that would require a doctor's permission to workout?

Yes

No

Do you have any medical conditions, that may make it hard for you to lose weight?

Are you pregnant or trying to get pregnant?

Yes

No

Are you nursing?

Yes

No

How many meals/day are you eating?

3

3-4

5-6

How much alcohol are you consuming on average?

<1/week

1-2/week

2-3/week

more than 4/week

I have a tendency to binge drink on weekends 5+ drinks at a time

There are no judgements, this information will help me better provide you with a plan.

If you are currently using supplements, please let list them.

What goals would you like to acheive in the next 30 days?

On a scale of 1-5 how commited are you to achieving your goals. *

1

2

3

4

Is there anything else I need to know.

I have read and agreed to the Terms and Conditions of this website. *

Medical Wavier -- https://www.kimbarnesjefferson.com/medical-disclaimer/

Website Privacy policy -- https://www.kimbarnesjefferson.com/website-privacy-policy/

Website/URL

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• 4 — 30 min private phone sessions
• 2 workout programs
• Nutrition plan

Total cost $260 — click on button below to purchase services.