Email
First name
Last name
Phone number
How did you find out about me? -- select an option --
Recommendation from a friend
Social media (Facebook, LinkedIn, etc.)
Search engine (Google, Microsoft Bing, Yahoo, etc.)
Customer testimonials
Gender -- select an option --
Female
Male
Prefer not to say
Age -- select an option --
Under 20
20 to 30
30 to 40
40 to 50
50 to 55
Over 55
What's your fitness experience level? -- select an option --
1 - Beginner
2 - Intermediate
3 - Experienced
Have you ever been assessed by a movement specialist? -- select an option --
Yes
No
Are you able to make time in your schedule to fully commit to your training? If so, what time(s) of day are best for you? And how much time do you have to give (10 mins, 30 mins, 1 hour etc.)?
Where do you plan to train? -- select an option --
My Home
A Facility
Hybrid - At Home / At Facility
Brief health history... List any medical limitations, injuries, surgeries (both current and past).
Are you mindful of what you eat? Do you make healthy food choices? -- select an option --
Yes
No
Are you drinking enough water throughout the day? -- select an option --
Yes
No
Are you having too much coffee, soda and/or alcohol? -- select an option --
Yes
No
Are you interested in nutritional guidance? -- select an option --
Yes
No
Sleep... How are you sleeping? How many hours do you average per night?
Environment... Is your environment conducive to healthy living and exercise? -- select an option --
Yes
No
Support... Do you have family and friends that will support your health journey? -- select an option --
Yes
No
Quiet time... Do you have time without noise or distraction during the day that is just your time? -- select an option --
Yes
No
Hobbies/activities... Do you have any hobbies or activities that make you feel happy and excited? If yes, elaborate.
Do you practice self-love? Are you kind to yourself? Do you appreciate and love your body? -- select an option --
Yes
No
What's your mindset? (1 - Negative, 10 - Positive) -- select an option --
1
2
3
4
5
6
7
8
9
10
What is your #1 struggle to improve your health, fitness, nutrition, strength, mindset and/ or overall well-being?
Are you ready to commit yourself to a coach that will keep you accountable? If yes, what is your number one reason "why"?
Please add any additional application information here that you would like me to know.
DISCLAIMER: I acknowledge that “Coach Kerry Seppa / The Functional Body” in no way intend to diagnose, treat, cure or prevent any disease through any services or programs provided. I do hereby waive, release and forever discharge “Coach Kerry Seppa / The Functional Body” from any and all responsibilities or liability for injuries or damages resulting from my participation in any activities, programs or use of equipment or machinery at various sites, including home, club, office or elsewhere. It is recommended to always consult your physician before beginning any exercise program.
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