Name *

First Name

Last Name

Phone *

(###)

###

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Generally speaking, which of the 2 categories, do your health goals fall under? *

Lose weight

Gain muscle

Within the next 3 months, which of the 2 following goals, would you rather reach? *

Losing 15 to 30 lbs or more (7 to 14 kg)

Gaining 5 to 10 lbs of muscle (3 to 5 kg)

On a scale of 1 to 10 how serious are you in reaching these goals? (1 being not important at all and 10 being it is one of the most important goals for me to reach) *

1

2

3

4

5

6

7

8

9

10

Will you be in a place at our call time where you’ll be fully present and focused? *

YES

no