Client Intake FormThank you for your interest in my coaching services and for allowing me to be a part of your transformation process. This form allows me to get to know you while providing key information to design a customized program that fits your needs.

i.e. a bad example would be: "I want to be skinny" a good example: "My goal is to lose 5% of my total body weight within the next 6 months."

i.e. Increased energy and confidence, ability to play with grandchildren, improved sleep, stress relief, relationship with partner etc.

i.e. "Running," "Plyometric/Jumping Movements"

ATTN**Please send a picture/video of your gym set up to my email or cell if you have a home or apartment gym**

i.e. enjoyed frequent texts for motivation, weekly check-ins, mentorship, etc.

i.e. I need to know the date and extent of the injury, if you've had surgery or physical therapy, if pain still exists etc. This information will help me include exercises in your program to help you overcome your injury vs. making it worse. For example, if you've had a knee injury, I don't want to have you doing any jumping, lunging or running exercises. We would work on low impact knee strenthening exercises instead. A good example: I tore my ACL in 2015, had surgery in 2015 to repair, did 6 months of physical therapy, I have minor pain climing stairs and running. Please be very specific.

i.e. Insulin - type 1 diabetic, Lexapro (escitalopram) - Anti-depressant, Apixaban (Blood Thinner) - for heavy periods, Acebutolol (Sectral) - Beta Blockers - Reduce high blood pressure

Please use this space to add any information your coach should know.

**Be SPECIFIC, instead of "breakfast sandwich," write "breakfast sandwhich - two slices of whole wheat bread, two fried eggs, 1/2 avocado and an 8 oz glass of apple juice."

**Be SPECIFIC, please don't say, "chips," or "yogurt & fruit." I need to know what kind of chips, how many servings do you typically have? A snack size bag or a family size bag? What brand of yogurt? How much yogurt? What type of fruit? Mixed berries or a banana?

**I will use this information to avoid adding these foods into your meal program**

i.e. Dash Diet - Decreased Hypertension. Limited processed carbohydrates, PCOS, helped me lose weight fast. Gut cleanse, etc.

i.e. Protein Powder, Creatine, BCAA's, EAA's, Pre-Workout Multivitamin etc. Please include the brand.

**Our bodies tell us when we are drinking enough water, ideally urine should have a faint light-yellow hue**

Add any other nutrition related information here.

**Be specific, I will base your caloric intake off this information**

**Be specific, I will base your caloric intake off this information. Even +/- 5 lbs can make a drastic difference.

i.e. electrician (on feet all day, overhead work); Secretary (desk job, seated most the day)

i.e. hiking, mountain biking, motorcross, walking your dog etc.

i.e. Seltzer beer, whiskey coke, martini (vodka), etc. For weightloss, low calorie beer, vodka and tequila are best to consume but we want to limit consumption as much as possible.

Please add any other lifestyle information here.

i.e. chronic back pain, torn ACL: 6 months PT, pain in low back while squatting

If you answered YES to one or more of the above questions, consult with your physician before engaging in physical activity. After a medical evaluation, seek advice from your physician on which activities are suitable for your current condition. I will need a signed doctor's note with training limitations. 

Please sign below to acknowledge you've answered the questions within this Training, Nutrition and Medical (PARQ) Questionnaire to the best of your knowledge.

By signing, you also agree to disclose any injuries, illnesses, or known medical condition, medications, or similar information that may occur during your programming to ensure your safety & effectiveness.

All sessions must be paid in-full, prior to scheduling.

A single session will be scheduled each week and will last approximately 55-minutes in duration. If you require more time and attention, additional sessions can be added at cost.

A 24-hour notice is required to reschedule a session. A written 30-day notice is required in order to terminate your training and/or nutirtion contact with Lifted. Being 15+ minutes late to a session will result in the loss of the session w/o refund.

An appointment can be rescheduled without penalty with a 24-hour notice.

If a session is late cancelled or "no showed," I forfeit the cost of the session and will have to make payment to reschedule. No adjustments will be made to a clients program without a session.

The applicant of this intake form acknowledges and understands Lifted has a zero tolerance policy toward sexual harassment. Any form of sexual harassement, to include asking me on a "date," will result in immediate termination without refund. I am a fitness professional here to help you reach your goals & assist you in the transformation process to become a better version of yourself. I uphold a strict policy & do not date my clients. Thank you for your understanding.

If any client of mine refers a new client to me, and that client purchases 4+ sessions, you will automatically receive one free session valued at $80. Refer four clients and you will receive a FREE month of coaching while also helping your friends and family reach their health and fitness goals. 

Once you've clicked submit and sent payment, I will add you to my client roster. You will receive an email to set up your client profile on my training platform. Once you've ceated your profile, you will be given direct access to the Lifted training app. From the app, you will be able to access your workouts, training schedule, nutrition, assessment, upload progress photos & more! After going over your intake form, I will reach out to get your first appointment scheduled to create your program! Once again, thank you for allowing me to be a part of this tranformation process. I am excited to work with you!

-B