Coaching Application

Thank you for your interest in 365 F2F nutrition coaching!

This application helps determine your journey and ensures

you receive the level of support you deserve.

Limited space is available: Applications are answered and services are rendered in the order they are received.

This form is in confidentiality and all information is kept between Amy Gear and the client

*All Fields are required

There are no right or wrong answers—just honesty.

Basic Information

First name

Last name

Email

Phone

Preferred Method of Communication:

Text

Email

Both

If this session fills, would you like to be contacted for the next session?

Yes

No

Goals

Habits

Describe your current eating patterns

I Eat Meals

Graze/Snack Throughout the Day

Sometimes I Fast

Eat When I Can

Select All that Apply

Lifestyle

Do You Cook Most of your Meals?

Yes

Some

Rarely

How Many Days per Week Can You Prepare Simple Meals at Home?

0

1-3

4-5

More than 5

What Level of Support do You Need?

Weekly Guidance

Weekly Check-Ins/High Touch Support

Short-Term Reset

Long Term Habit Coaching

Coaching

Are you Open to Consistent Communications?

Yes

Somewhat

Not Sure

Are you Willing to Focus on Habits and Consistency Over Perfection?

Yes

I'm Learning

This is New For Me

If You're Comfortable, Would You be Willing to Take a Photo to Mark Your Starting Point?

Yes

No

Readiness

On a Scale of 1-10, How Ready are You to Make sustainable Changes?

Describe Your Activity Level

Sedentary

Lightly Active

Moderate

Very

Q&A

What Made You Seek Nutition Coaching at This Time?

Have you Followed Meal Plans/Diets in the past? What Worked and Didn't Work

Do You Have any Dietary Restrictions? (Vegan, Vegetarian, etc)

What Would Success Look Like to You After the Help of Nutrition Coaching?

Is there Anything Else You'd Like me to know About You, Your History with Food, or Your Goals?