Client Form

Thank you for submitting your form!

We appreciate your interest and will review your information as soon as possible.

Our team is dedicated to providing excellent customer service, and we will do our best to respond promptly.

Basic :

Full name *

Email Address *

Age *

Height *

Current Weight(Optional)

Country *

Life Stage & Hormonal Context :

Which best describe your current stage *

If peri- or post-menopausal, are you experiencing any of the following? (Select all that apply)

Hot flashes Night sweats Sleep disruption Mood changes Increased abdominal fat Low energy Joint stiffness

Are you currently using hormone therapy or hormonal medication? *

Yes No

PRIMARY GOAL & READINESS :

What is your main goal right now? *

Fat loss Body recomposition Energy & consistency

Why is this goal important to you at this stage of life? *

On a scale of 1–10, how ready are you to follow a structured plan for the next 12 weeks? *

CURRENT EATING & LIFESTYLE :

How many meals do you typically eat per day?

Do you snack between meals? (Yes / No)

Biggest struggle with food right now: *

Cravings Emotional eating Overeating Lack of structure

17.Average sleep per night :

Current stress level (1–10): *

HEALTH & SAFETY :

Do you have any diagnosed medical conditions? *

Are you currently:

Pregnant Postpartum (within 1 year) Breastfeeding

Are you taking medications that may affect weight, appetite, energy, or sleep?

Any injuries, pain, or physical limitations relevant to exercise?

MINDSET, PATTERNS & EMOTIONAL CONTEXT :

30.When progress slows, what do you usually do? *

Quit Restrict more Overthink Lose motivation Push harder

What feels hardest about trying again right now? *

What would success look like for you in 3 months — beyond the scale?

SUPPORT & EXPECTATIONS :

What kind of support helps you most? *

Clear instructions Reassurance Accountability Education

Are you comfortable with written feedback and no live calls? *

Yes No

What are you hoping coaching will help you with most?

FINAL CONFIRMATION :

Are you willing to follow the program as designed and communicate honestly? *

Yes No

Anything else you’d like me to know before we begin?

By submitting this form, I confirm that the information provided is accurate to the best of my knowledge and that I understand this coaching program is educational and not medical treatment.

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