Home
Programs
Blog
Freebies
Contact us
Contact us
Intake form
Contact information
Name
(Required)
Pronouns
(Required)
She/her/hers
He/him/his
They/them/their
Other (if you're comfortable, specify in the last question of the form!)
Date of birth
(Required)
DD slash MM slash YYYY
Phone number
(Required)
Email
(Required)
Instagram handle
Occupation
Emergency contact name
(Required)
Emergency phone number
(Required)
Program
We think I'm a good fit for
(Required)
1:1 Coaching
Group Mentorship
The Rebel Roadmap
Other
Medical history
Are you currently taking any medications or health supplements? If you’re comfortable, please specify type, dosage, and reason for taking.
(Required)
Do you have any allergies?
(Required)
Have you ever experienced any problems with sleep? If yes, please explain.
(Required)
Have you ever experienced any problems with digestion? If yes, please explain.
(Required)
Do you have any other medical conditions that have not been mentioned so far that are relevant to your nutrition journey?
(Required)
Health & nutrition
Why are you looking for nutrition coaching?
(Required)
What can you tell us about your current nutrition, eating habits and/or fitness?
(Required)
Do you currently follow a specific nutrition plan or way of eating? If yes, please explain.
(Required)
Have you tried anything in the past to change your habits, your health, your eating, and/or your body composition? If so, what?
(Required)
Which of those things worked well for you (even if you may not be doing them right now)?
(Required)
Which of those things did not work well for you?
(Required)
Do you take part in physical exercise? If so, what and how often?
What degree of stress are you under on a scale of 1-10 (10 being highly stressed)? Why did you choose the answer you did?
Developing your program
What are your nutrition goals (ex: lose weight, gain weight, feel better, increase energy, improve understanding of nutrition, improve athletic performance)?
(Required)
How would you like your habits, health, eating and/or body composition to change?
(Required)
How long have you been thinking of these goals?
(Required)
Until now, what has held you back from these goals?
(Required)
If you achieved these goals, how would you feel?
(Required)
Realistically, how much time can you dedicate to this process?
(Required)
What are the best days/times during the week for you to commit to your coaching program?
(Required)
What do you feel are the obstacles that could challenge your journey to your goals?
(Required)
Our coaching relationship
Some patterns I notice in myself are…
People pleasing & burning out if I’m not actively setting boundaries.
Working for the sake of productivity & ‘getting shit done’.
Needing things to feel ‘perfect’ to take action or feel good about them.
Going ALL in on things & then ghosting when my energy shifts.
Why do you want to work with a nutrition coach?
(Required)
As a human, I identify most with…
Having big ideas & tending to “wing” things.
Loving relationships & needing time to make decisions.
Knowing what I want & going after it.
Living & breathing by a plan; I feel better when things are detailed & organized.
Describe your ideal coaching relationship? What is a coach's role in your nutrition journey?
(Required)
As a client...
I like to move slowly & take my time understanding/incorporating new ideas.
I really like structure & when I’m clear on the task, I don’t hesitate.
I have big ideas & need someone who won’t shut them down regardless.
I don’t need my hand held, but I appreciate support & close communication.
Anything else you’d like me to know about you? Personality? Needs? Core values? Anything that would help me get a better sense of YOU is totally encouraged here...go wild!
(Required)
Acknowledgment, participant release & cancelation policy
Consent
By checking the boxes below, I acknowledge and agree to the terms as stated below.
Consent
I understand and agree that it is my responsibility to inform Rebel Nutrition of any condition or changes in my health that might affect my ability to complete the program safely.
Consent
I agree that Rebel Nutrition shall not be liable or responsible for any injuries to me resulting from my participation and I expressly release and discharge Rebel Nutrition from all claims, actions or judgments as a result of any injury or damage which may occur in connection with my participation.
Consent
As a client, I agree to participate fully in the program via tracking, check-ins and calls and immediately inform my coach of any issues or difficulties I may have with the program.
Consent
I understand that Rebel Nutrition operates on a scheduled hourly appointment basis and that I must provide a minimum of 24 hours notice if I need to reschedule an appointment. Where less than 24 hours notice is given, I understand that rescheduling will not be possible. My coach will utilize that time to further develop my nutrition plan.
Consent
I agree to an initial 3-month commitment to my coaching with Rebel Nutrition. After three months, I understand my contract will automatically renew on a month-to-month basis. I agree to give notice of 1-calendar-month via email to hello@wearerebelnutrition.com in order to cancel the contract. I acknowledge that there are no refunds available on this investment.
Phone
This field is for validation purposes and should be left unchanged.