Application Form

Take a few minutes to complete this short questionnaire. This information will be helpful for me to build a profile about you and what we aim to achieve together. It will help me to understand where you are right now and where you would like to be including any obstacles we can address. Please answer everything honestly, there’s no judgement here.

Once you have completed the form – Hit the APPLY button. You will then receive an email from me explaining the whole process in more detail and how to get started. We can also set up a telephone consultation for us to go through everything together so that you become fully comfortable with the system. Congratulations – you are a step closer to changing your life!

Personal Information:

Your Name (required)

Age (required)

Gender (required)

Telephone (required)

Email (required)

Getting to Know You:

What is your favourite music album/CD of all time? (required)

What is your favourite place in the world? (may be a childhood memory) (required)

Do you have a favourite quote? (may be a childhood memory)

Medical Information:

Have you been in hospital or had medication prescribed to you in the last 5 years? (required)
YESNO

Please List:

Do you ever get any unusual or uncomfortable feelings anywhere in your body when being active or at rest? (required)
YESNO

Please List:

If you know any of your blood pressure, cholesterol, and Blood glucose (pre and post prandial) readings, please state them.

Is there anything about you or your health that you may want to discuss with be before we start working together?

Your Aspirations:

If I had a magic wand what could I grant you? (required)

What best describes you right now? (mind and body)(required)

At what point in your life were you the most happy and fulfilled about yourself? (required)

What obstacles do you see from getting you back there? (required)

If you could change one thing about yourself, what would it be? (required)

What do you hope I can help you with? (required)

Why did you specifically apply to my online coaching? (required)

Have you ever tried to get in shape or lose weight before? (required)
YESNO

If yes what methods/programmes have you followed?

Your Thoughts and Beliefs:

Do you feel motivated to change? (required)

What food/drink would you love to have every day if it was calorie free? (required)

From a scale of 1 - 10. One being "I love crashing on the couch with something I enjoy" to 10 being "I get excited when I think of exercising "- What number describes you now? (required)
12345678910

Do you believe with the right help and support you can change? (required)
YESNO