Consulting Application

1 Step 1

Choose your coach

Leslie Hooper (one-time $149 consultation fee)Steph Miramontes (one-time $99 consultation fee)

Calendar

First Name

Last Name

Age (applicants must be 18 or older)

Phone number

Skype username

In general, what is your goal?

Please list the concerns you have about your health, eating habits, fitness and/or body.

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Out of all of the above concerns, what sounds the most important/urgent? Why?

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Right now, on a scale of 1-10, how consistent are you with your current eating habits?1 being inconsistent, 10 being very consistent.

If you’re less consistent than you’d like, what seems to be the obstacle?

Do you feel like you have trouble controlling your appetite/hunger?

YesNo

Do you struggle with food cravings?

YesNo

Do you have a history of binge eating?

YesNo

Have you ever noticed a connection between your emotions and eating habits?

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If yes, what happens?(e.g. When I have a work deadline, I get stressed and nose-dive into a pint of Ben & Jerry’s Chunky Monkey)

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Thinking about everything you’ve responded to here, what do you think you might start to like working on or addressing first?

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What do you expect from me as a Coach?

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How much is your dream body worth? What are you willing to invest to achieve this goal?

Price

Item		Total
Consultation Fee	1	[field51]

Annual Charge $xxx