January 2018 Online Program Application Form
I'm excited to learn more about you. 

There are only 6 spot available for this program.  It is designed to help busy professionals add health and fitness into their lives. 

Once you have completed the questions we will set up a time to chat further to find out if you and I are the best fit for one another and if this program will help you achieve your goals.   

All of your answers are only read by myself, Andi Clark and are kept confidential.   The more real your answers are the more I will be able to help you.  

I am excited to read your application and get you started on your health and fitness journey.
What is your first name *

What is your last name? *

What is your mobile number ?

How did you hear about us?

Where do you live?

City and Country
How old are you?

Total years on this planet.
How old do you feel?

What are your goals?

Why are your goals important to you?

Please list all of your concerns about your health, eating habits, fitness and/or body. 

What are you prepared to do to work towards your goals?

How would you rate your current health right now?

1 being very poor 10 being there isn't any room to improve it.

Have you ever been diagnosed (currently or in the past) with any significant medical condition(s) and/or injuries?

Right now, how would you rate your overall eating/nutrition habits?

1 being horrible and 10 being awesome.

Do you currently exercise?  If so, describe your routine?

What challenges, if any, do you find when trying to stick with a fitness program?

How do you feel about your schedule, time use, and overall busy-ness?

1 is My Life Is Panicked and Insane.    10 is My Life is Perfectly Calm And Relaxed

On average, how many hours per night do you sleep?

Given all of the demands on your life, what is your typical stress level on an average day?

1 is no stress   10 is extreme stress

How do you normally cope with stress?

How ready are you to change your habits and behaviours?

1 Not At All   10 Completely

How Willing are you to change your behaviours and habits?

1 Not At All   10 Completely

How able are you to change your behaviours and habits?

1 Not at all   10 Completely

Have you ever had a lifestyle, fitness and nutrition coach before?

What do you expect from me as your coach?

Do you consider yourself a coachable person?

Is there anything you feel that would stop you from being able to work towards your health and fitness goals once you start this program?

Thank you for your replies.   I'll be in touch shortly to set up a call.
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