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Jack Drapkin Coaching - Client Intake

Thanks for your interest in coaching. Fill this out honestly — it takes about 5 minutes, and the more detail you give me, the better I can build your plan. I'll review this and get back to you within 24 hours.

About You

Age

What do you do for work?

Are you married? Do you have kids? If so how old are the kids?

Your Body Right Now

Current height

Current weight

If you had to guess your body fat percentage, what would you say? (Fine to say "no idea")

Any injuries, surgeries, or chronic pain I should know about?

Any medications that might affect your energy, appetite, or weight? (You can be general — "blood pressure meds" is fine)

When's the last time you were in the shape you wanted to be in? What did that look like?

Your Current Habits

What does your typical weekday look like, hour by hour? (Wake up, work, meals, family time, bed — rough sketch is fine)

What are you currently doing for exercise? Be honest — "nothing" is a valid answer.

How would you describe your current diet? (Don't sugarcoat it — I need the real version, including the weekend version)

How many alcoholic drinks do you have in a typical week?

How many hours of sleep are you getting on average?

Your Goals and Commitment

What's your #1 goal for the next 3 months? Be as specific as you can.

What have you tried before that didn't work? Why do you think it failed? → Long text, required

How many days per week can you realistically train? (Not "want to" — can you, given your actual life?)

Do you have access to a gym? If so, what kind? (Commercial gym, home gym, hotel gym, etc.)

On a scale of 1-10, how ready are you to actually commit to this for 3 months? If you're below a 7, tell me what's holding you back.

Logistics

How did you hear about me?

Any questions for me before we schedule a call?

By submitting this form, you understand that coaching is a 3-month minimum commitment at the agreed-upon monthly rate. Payment details will be shared after your kickoff call.