Join us on Facebook & Twitter
Home
Services
Personal Development
Behavior Change
Fitness Coaching
Group Fitness
Nutrition Planning
Free Resources
Daily Caloric Intake
Body Fat Calculator
Exercise Routines
About Us
Feedback
Contact Us
>
Client Information Form
Download / Upload
Ask a Coach
Client Information Form
Welcome!
Prior to your coaching appointment, please complete the following questionnaire and click the "submit" button at the bottom of the page.
It should only take about 5 - 10 minutes to complete, so please answer the questions thoughtfully and honestly in order to help your coach make the most of your session!
Upon a successful transmittal of your form, you should receive a pop-up message informing you that your intake form has been successfully submitted.
Please call: (469) 952-0005
should you have any problems.
You may also email:
coach@FireAndHeart.com
*
Indicates required field
Gender
*
Female
Male
Date of Birth
*
Month/Day/Year
Name
*
First
Last
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Phone Number
*
Please enter the # by which you're most easily reached.
Type of Phone
*
Cell
Home
Work
Alternate Phone Number
*
Type of Phone
*
Cell
Home
Work
Your Email Address:
*
Additional Comments Regarding Contacting You:
*
Please enter best time to call or any additional comments regarding contacting you.
Occupation
*
Voucher Number or Coupon Code (if applicable):
*
If you have a voucher number or coupon code, enter it here. (i.e. Living Social, Amazon Local, or Google Deals...)
Please describe the reason for your coaching appointment:
*
Describe the issue you'd like to improve through working with your coach.
What methods have you attempted in the past to resolve your issue(s)?
*
What might be some of the possible reasons these issues haven't been successfully resolved in the past?
*
Describe your PRIMARY goals for your coaching experience:
*
Describe your SECONDARY goals for your coaching experience:
*
Are you comfortable utilizing hypnosis as one of the tools to assist you in reaching your goals?
*
Yes
No
Describe your thoughts of hypnosis & any prior familiarity or experience you've had with it.
*
Are you currently under the treatment of a medical or psychological professional regarding this or any relevant issue?
*
Yes
No
If so, please describe the nature and status of the treatment and provide his or her contact information.
*
Please share anything else you'd like your coach to know:
*
How confident are you that you'll somehow eventually resolve these issues?
*
Absolutely certain
Very confident
Mildly confident
Fairly unconfident
Not much faith at all
How motivated are you to improve your current condition?
*
Completely motivated
Very motivated
Mildly motivated
Not very motivated
Not motivated at all
Submit
"We are, what we repeatedly do. Excellence, then, is not an act, but a habit."
William Durant