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Thank you for your interest in working with Excelerate Wellness!

Please complete the application below and we will be in touch shortly.

First Name *

Last Name *

Email *

Phone *

Instagram Handle or Facebook Name if you prefer to be contacted there

Occupation? (Where do you work? Desk job? Active job? etc.) *

Please describe your top two current goals. Ex: lose 20lbs, tone up, overcome anxiety, have more energy, balance hormones, etc. *

How long have you been working towards this and what are your biggest challenges? *

What have you tried in the past and why hasn't it worked for you? What has kept you from achieving your goals? *

Explain to us WHY. What is driving you to make these changes? *

On a scale of 1-5, how ready / committed are you to changing your life right now? (1 being "not ready at all" and 5 being "I'll do anything to change my life") *

1- I could put this off for awhile

5- I want this change now!

Are you currently using any food tracking app? *

If not, are you open to learning how?

At this time, do you exercise at home, in the gym, or not at all? *

Are you looking for a very structured plan or does something more flexible sound appealing to you? *

What do you believe you need most from a coach in order to create the results you want. *

How committed are you to your health goals? *

Not very committed

Pretty committed

Extremely committed

If we determine this is a good fit, are you prepared to invest financially in a high-touch coaching experience? *

Yes

Possibly, I'd need more information

Have you done other programs in the past? Please describe any reservations you may have. *

Who else is involved in your decision-making process and would they give you a thumbs up on whatever you decide to do? *

If we decide we are a great fit to work together would you be able to begin in the next 30-60 days?

Yes

Maybe

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