Intake Forms - FIX it CHANGE it

Select the proper form for your scheduled meeting:

Personal Finance Intake Form

Fill out this form if you have scheduled a meeting with Sonya for personal spending plan coaching.

Health Coaching Intake Form

Fill out this form if you have scheduled a meeting with Sonya for health coaching.

Name

Phone Number

Mailing Address

Share a bit about your life.... About your family? Are you currently working? Favorite hobbies? Etc.

What would you like to accomplish with your health (weight loss, improved sleep, improved response to stress, etc)?

What is your primary motivation for wanting to make changes to your health (relationships, activities, how you will feel, how you will look, events coming up, children, grandchildren, etc)?

Are you taking any medications and what are they for?

Do you have any allergies to food? Soy, gluten, etc.

What is your current age?

What is your current weight and height?

What is your desired weight?

Who in your life desires to get healthy with you? Spouse, best friend, etc.

How many hours of sleep do you get in a typical night?

How would you describe your quality of sleep?

How many days a week do you exercise and type of exercise?

What type of physical activity do you enjoy?

On a scale of 1 to 10 how fulfilled are you with where you are now with your health? (1 = not fulfilled; 10 = very fulfilled)

What area of your life tends to be the main stress for you?

How many meals do you eat per day?

How many snacks do you eat per day?

How many hours after waking do you eat or drink something?

How many ounces of water do you drink per day?

How much coffee, soda, energy drinks, and/or alcohol do you drink per day?

How many times do you eat out per week?

How much of that is fast food?

What type of employment do you do for a living? Is it a lot of moving around or stationary?

On a scale of 1 to 10 how ready are you to do what it takes to make changes you need to become who you really want to be?

Please Select All That Apply To Your Situation (REQUIRED TO SET APPOINTMENT)

Health concerns Learn to eat healthier Medication concerns I do not like the way I look or feel about my body

Whom Can I Thank For Referring You?

Whether you want to FIX it or CHANGE it, I will support you!

Let’s schedule our discovery meeting. We will meet over coffee, so we can relax and get to know one another without pressure and interruptions. Once we have a plan, we will move forward toward your goals and bring you peace of mind!

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Get In Touch

Cecilia, LA

sonya@fixitchangeit.com

+1 (337) 849 2279

09.00 AM - 5.00 PM