Intake Form - Mary Vance Lifestyle

Coaching Program Intake Form

Helping high performers reclaim their energy, strength, confidence, and appearance through personalized nutrition, lifestyle, and body transformation coaching.

First and last name(Required)

First Last

Email(Required)

Enter Email Confirm Email

Birthdate(Required)

Mailing address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone number(Required)

What kind of lifestyle coaching are you applying for?(Required)

Basic - Nutrition

Advanced - Nutrition, Fitness, & Bodysculpting

I am unsure of what will best suit my needs and would like to determine that in our consultation.

What are you as an individual desiring to gain from receiving nutritional guidance and lifestyle coaching? Your desires dictate the plan. Please be specific and HONEST.

How long are you currently desiring to commit to this program?(Required)

12 weeks

26 weeks

52 weeks

Please submit a 3 consecutive day journal of the foods you are currently eating. Include the timing of your meals. Include current daily water and beverage intake. Include vitamins, supplements and pre/post workout nutrition as well. This is easy. Track everything that goes in your mouth for 3 days. AND JUST DO YOUR BEST. Do not worry if it's not perfect.(Required)

This is mandatory. We will not have our initial meeting without this information submitted prior to the meeting. (Some people take pictures of everything they eat right before they ingest it throughout the day and then write it up in the evening. I prefer you use myfitnesspal or another food tracking app from your phone or computer to log the data, however, I will accept a photo of a handwritten format.) This can be typed in the box below OR sent to maryvancelifestyle@gmail.com.

Do you have any diagnosed allergies or sensitivities to foods? If yes, please list the foods.(Required)

Do you have any foods that give you any problems although you do not have a diagnosis?(Required)

Examples: Dairy gives me gas. Strawberries give me a rash. Eggs give me a stomach ache. Bread makes me feel bloated. I tend to overeat chips and cookies. If yes, please list the foods.

Do you have any health concerns that you want to share with me that may affect your dietary needs?(Required)

If you would prefer to share in person or via zoom, that is okay. Examples: Diabetes, Pregnancy, Renal dysfunction, Cholesterol concerns, History of eating disorders, Mood swings, etc. You may also include any blood work or specialized test results.

What is your current physical activity and/or training schedule level? Please list your 7-day training/exertion schedule. This is mandatory.(Required)

Example: Monday-Friday: I walk 30 minutes at lunch. Saturday: 1 hour yoga. Sunday: 1 hour gym.

How many hours of sleep do you get per night on average?(Required)

How much water in liters or ounces do you drink per day?(Required)

List your 5 favorite Proteins:(Required)

(Examples: eggs, red meats, fish, soy, poultry, shakes, bars, plant based, etc)

List your five favorite Fats:(Required)

(Examples: butter, bacon, oils, nuts, avocado, coconut oil, chocolate, nut butters, dairy, etc)

List your 5 favorite fruit Carbohydrates:(Required)

List your 5 favorite non-starchy vegetable Carbohydrates:(Required)

(Examples: broccoli, peppers, spinach, lettuce, asparagus, tomatoes, greens, etc)

List your 5 favorite starchy vegetable Carbohydrates:(Required)

(Examples: sweet potato, white potatoes, corn, peas, root vegetables, legumes , etc)

List your 5 favorite starchy grain Carbohydrates:(Required)

(Examples: corn, rice, oats, pasta, quinoa, bread, barley, etc)

List your 5 favorite beverages:(Required)

List your 5 favorite sugary treats or “junk” foods:(Required)

List 5 favorite restaurants or fast food restaurants:(Required)

I, ____________________________, am entering into this Coaching Program of my own free will.(Required)

My specific focus of intent and major goal/goals for entering into this agreement is/are to improve the quality of my life by:(Required)

I will be honest and gentle with myself as I make the necessary changes in my thinking and in my daily actions in order to reach my goals. I accept that in order to improve my overall health consciousness I need assistance, guidance, knowledge and discipline. I will follow through with my individualized plan on a daily, weekly and monthly basis. I will honor my monetary agreements with Mary Vance Lifestyle, LLC. I acknowledge that this is not a medical program or weight loss program. I am aware that this is a Lifestyle Change Coaching Program offered by Mary Vance to assist me in reaching my short term and long term goals that are in alignment with my desire for greater health and well-being.(Required)

Type full name below to affirm you have read this message. **You will be required to sign and mail in a hard copy of this agreement after initial consultation before the first session in the program.**