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The Nourish Method - Intake Form

Hi and welcome! I am excited to hear about your goals and help you on your health journey.

Please take a moment to complete this short intake form so I can get to know you and your goals. I’ll be in touch shortly with the next steps, at which point you can decide how you’d like to proceed.

Full Name

Email

Phone Number

1. What is your primary nutrition goal?

Fat loss/ body composition

Improve food quality

Increase clarity and skills around healthy food choices

Improve energy levels

Manage a medial condition

Other (please describe below)

Have you attempted this goal before? If so, please briefly describe what you did, what worked, and what did not work?

2. What is your biggest barrier in achieving your goal?

Motivation

Consistency

Time

Work commitments

Family commitments

Emotional eating or cravings

Confidence in food choices

Other (please describe below)

Would you like to integrate Fitness Coaching into your program?

Nutrition is your foundation, movement is the architect of your health during menopause. Let me know below if you would like to be sent more information regarding fitness coaching.

Would you like to integrate Fitness Coaching into your program?

No thanks, I’m just focusing on my nutrition for now.

Yes, I’m in Adelaide and interested in 1:1 Personal Training sessions.

Yes, I’m interested in Online Coaching (A custom program I can follow at my own gym/home).

3. How motivated are you to achieve your goal? (1 star = not motivated at all, 5 stars = extremely motivated)

1 stars

2 stars

3 stars

4 stars

5 stars

The Nourish Method - Intake Form

Full Name

Email

Phone Number

1. What is your primary nutrition goal?

Have you attempted this goal before? If so, please briefly describe what you did, what worked, and what did not work?

2. What is your biggest barrier in achieving your goal?

Would you like to integrate Fitness Coaching into your program?

3. How motivated are you to achieve your goal? (1 star = not motivated at all, 5 stars = extremely motivated)

Is there anything else you would like me to know? (e.g. medical conditions, concerns, background etc)