Intake & Assessment Form

WELCOME TO YOUR NEXT STEP!

Now that you have made a committment to begin coaching, we are going to ask you form some information so we can connect you with the Coach Me Strong coach best suited for you individual needs.

This information is confidential and is protected and encrypted according to HIPAA standards. Only the Coach Me Strong management team and coaches have access to this information. You can expect us to contact you within 48 hours to review your information, talk through any additional concerns, then recommend one or more coaches. You are then welcome to contact each of our coaches prior to making a final decision on who will be your new coach.

Please contact us anytime with any questions.

Ready for step two? LET’S GET GOING!

"*" indicates required fields

GENERAL INFORMATION

Name*
MM slash DD slash YYYY
Email*
Address*
MM slash DD slash YYYY
Gender*
Are you currently employed?*

MEDICAL HISTORY

MM slash DD slash YYYY
Do you have (or have you had) any of the following. If you check any item, please explain below.
Do you have (or have you had) any of the following. If you check any item, please explain below.

Please tell us a little about your exercise routines and history:

Does your current exercise routine include (please check all that apply):
Do you have a current gym membership?
Have you ever worked with:

Coach Me Strong General Release of Liability and Covenant Not to Sue