Name *

First Name

Last Name

Insurance

On receipt of this completed form, we will contact you to ask for a proof of insurance and as certified health coach. Please confirm that you will be able to provide this.

Yes

Commitment *

The programme will run in 12 weeks blocks. For consistency among participants, we kindly request a minimum commitment of: Weeks 1-4: Weekly 50min sessions Weeks 5-11: Alternate week 25 min sessions Week 12: Celebrate success 50 min session Please confirm this will be ok.

Yes, I'm able to commit to this.

No, I won't be able to commit to this.

Booking *

For managing bookings, we will be using a third-party scheduling software called Acuity. Have you had any previous experience working with this platform? If not, don't worry, as it is very straightforward to use.

Yes, I currently use / have used in the past

No, I've not used before

Approval *

Are you happy for us to contact you via email? We promise not give out your email address to 3rd parties - this is solely for us being able to manage the project and send you email updates.

Yes