Application for Nutrition Coaching

Please fill out the following form if you are interested in a one-on-one coaching space.

First name

Last name

Date of Birth

Do you have a doctor's note/order to change your diet/nutrition?

Yes

Are you suffering from a medical condition or illness?

Yes

If you answered yes to any question, please elaborate

Tell me a little about your current eating habits. What are the struggles with food you might have or diets you have tried in the past, etc.?

What are you hoping to get out of one-on-one coaching?

What makes now a good time for you to get coaching?

How important is it to you to get your eating habits sorted out?

Extremely - I'm willing to do what it takes.

Important - I know I have to make changes, but a little scared to get started.

A little important - I've tried things in the past and not sure anything will work

Not a priority at the moment

One-on-one coaching is a very persoalized approach and takes a big commitment. How committed are you to doing the work involved?

I'm ALL in and will do what it takes!

I need more information before I can decide if I can make it work

I know I need to make changes but not sure I'll have the time to commit at the moment

The1-month one-on-one coaching package is $500. Are you prepared to invest in yourself?

Yes!

Yes, but would need a payment plan.

I want to, but don't have the funds.

Not at this time.

Any other questions or comments?

I declare that the info I’ve provided is accurate & complete

Thanks for submitting! Michelle will be in touch!

Have a question?

Thanks for submitting!

Phone: 807-275-6081

Thanks for subscribing!

bottom of page