See if it fits you

What is your #1 Goal with Empower U Coaching?

Other (Please specify):

How much weight are you looking to lose?

How is your life enhanced when you achieve this goal?

Check all that apply:

I feel more confident and self-assuredI have improved health and reduced risk of chronic diseasesI experience less physical pain and discomfortI have a more positive body image and self-esteemI feel happier and more content with my life

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How would you describe your current support system for your health journey?

Strong support from family and friendsSome support from family and friendsMinimal support from family and friendsNo support from family and friends

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What challenges have you faced in achieving your health goals?

Other (please specify):

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How ready are you to make a commitment to your health journey?

Very readySomewhat readyNot sureNot ready

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On a scale of 1-10, how would you rate your current relationship stability?

1-3: Struggling - this contributes greatly to my stress4-6: Managing okay - i worry about it but it doesn't consume me7-9: Comfortable - i get more stressed about other things10: Very stable - it's not a concern, contributes no stress

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On a scale of 1-10, how would you rate your current financial stability?

1-3: Struggling - this contributes greatly to my stress4-6: Managing okay - i worry about it but it doesn't consume me7-9: Comfortable - i get more stressed about other things10: Very stable - it's not a concern, contributes no stress

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Do you currently have any health conditions or concerns we should be aware of?

YesNo

If yes, please specify:

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What are you looking for in a coach?

Other (please specify):

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Is there anything else you would like us to know about you or your health goals?

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Last step, let's get some basic info

Name

Phone number

Email

How did you hear about Empower U coaching?

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