Vital You Academy - Program Application

Please complete this application with as much detail as possible.

Email *

Phone *

Full Name *

What is your age? *

Please list any underlying health conditions *

Desired Health Changes - Please be specific (increase energy, weight loss, lower inflammation, work towards getting off medication, balance hormones, improve digestion, improve body composition, get toned, increase strength, reduce brain fog, reduce/eliminate headaches, etc.). *

How important is it to you to make each of these desired changes on a scale of 1-5? (With 1 being not important to 5 being very important) *

Current Weight and Height *

Goal Weight *

What have you tried in the past and why hasn't it worked for you? *

What have been your barriers in creating these changes for yourself? *

Paint me a VIVID picture of what would have to happen to you to feel like the program was the best decision you ever made. *

How important is it for you to reach your goals? (1 = Low importance, 5 = Very important - it means everything to me!) *

If you selected a 5 above, why are you a 5 now? (if you selected below a 5, please specify "N/A") *

On a scale of 1-5, rate how ready you are to enter a health coaching relationship right now. (1 = I am not ready, 3 = I think I'm ready, 5 = I am 100% ready and excited!) *

I will communicate and collaborate with my Health Coach and feel confident to ask for what I need. (1 = I am not comfortable with this at all, 5 = Yes, absolutely!) *

What would you expect from me as your coach if we decide to work together? *

My coaching approach is about teaching you sustainable nutrition and lifestyle practices to achieve long-term results (a lifelong plan, not a 'quick fix' plan). Are you willing to invest in yourself financially and emotionally to achieve these goals? Is this a "RIGHT NOW" thing or a "maybe later" thing? *

If this is a "maybe later" thing, what is holding you back? (If it is a "Right Now!" thing, please respond "N/A".) *

Does your family member/partner support you making decisions on your own, for your health? Both physically and financially, or would they need to be on the call? (if so, let's make sure they are on our next call). The more support you have the better your results will be! *

Will you be in a place at our call time where you will be fully present and focused? This call is typically 30-45 minutes in duration. *

I agree to terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from the business.