Name(Required) First Last Email(Required) Enter Email Confirm Email PhoneDate Of Birth Month Day Year How did you hear about Compass Human Performance?Google/internet searchFriend/familyGymOtherDo you have a healthcare provider?YesNoHave you ever worked with a human performance coach or establishment?YesNo What health goal are you currently pursuing or struggling with?How confident are you that you possess the skills, knowledge and structure to achieve this.1 (Not Much)2345678910 (Very Confident)What time frame do you believe is necessary to achieve this goal?0-3 mos3-6 mos6-12 mos12-18 mosLonger than 18 mos.What methods or therapies have you tried before to achieve this goal?What kept you from succeeding?What areas of your life will improve by reaching this goal? Financial Personal Family Fitness Longevity Sexual More time with loved ones Build treasured memories Be present and able for future family events How much time (weekly) can you commit to a wellness plan or to achieve this goal?90 min or less2-4 hours4-5 hoursmore than 5 hoursHow much did you budget monthly to achieve your goal?$0-$200$200-$400$400 or moreThis field is hidden when viewing the formHow much did you budget monthly to achieve your goal?On a 1-10 scale, how likely are you to follow a gluten free diet?12345678910This field is hidden when viewing the formOn a 1-10 scale, how likely are you to follow a gluten free diet?How do you view accountability, How much of the outcome are you responsible for?Percentage between 1-100.What/who is your support network?SpouseHome gymPersonal Trainer/PTClose Friend Anything else we should know?
