Consultation Intake Form

After you hit submit, you will be redirected to my calendar where you can choose the time that works best for you and reserve your spot.

Name

First Name

Last Name

I'm so excited to help you reach your health and fitness goals! Investing in yourself is the best investment you could ever make, because you get one body to live an amazing and long life in. Are you ready to show up for yourself and make the best investment yet?

Age

Gender

Height

Current Weight

Occupation

Activity Level

Give your best guess

Describe you current exercise routine (lifting & cardio):

Describe your past exercise routine:

What has been your biggest challenge to reaching your goals?

What have you already tried to reach this goal?

On a scale of 1-5, how ready are you to make this goal a reality? (1 being not ready and 5 being very ready)

Medical issues and/or injuries:

Do you have any pain from any exercises?

Physical activity outside of the gym/work:

What do you want to achieve by working with me?

Describe your current nutrition and what you eat on a daily basis:

Any food intolerances and/or allergies?

List any supplements you're currently taking:

Instagram Handle (or another social media if you don't have IG)

Email Address

Phone

(###)

###

####

How did you hear about Em-Powered Life?

Were you referred to this program by someone?

If yes,

please provide the name and number of the person.

Is there anyone you would want to review this with before taking the next step in your journey to a healthier you? (ie. husband, significant other, etc.)

We offer different payment options and terms. We try to work with everyone individually. If we can come up with a plan in terms of enrollment fees, and you feel like we can help you reach your goals, do you feel like you are in a place to invest in yourself and your health?

How soon would you say you're wanting to get started?

What time zone are you in?

Be sure to be in a place you’re fully present for your call with good internet/wifi. Will you be in a place where you're fully present?

Do you give consent to have your Consultation Call recorded for Quality and Training purposes?