INTAKE FORM

Basic Information

Full Name *

Email *

Age *

Country *

Profession - What do you currently do for work? *

Average Work Hours Per Week *

Relationship Status *

Are You Location Dependent or Location Flexible? *

ENVIRONMENT AUDIT

Where your current structure may be working against you

On a scale of 1-10, how aligned do you feel with the life you're currently living? *

Very LowVery High

What parts of your life currently drain your energy the most? *

What environments are you currently tolerating that you know are bringing you down? *

What would “earned freedom” realistically look like for you? *

STANDARDS & DISCIPLINE

How you live day to day

On a scale of 1-10, how would you rate your personal discipline right now? *

Very LowVery High

Where do you feel you’re letting your standards slip? *

What behaviours do you know are currently holding you back? *

What does your ideal daily routine look like? *

What habits do you struggle to maintain consistently? *

Do you rely on caffeine to maintain energy throughout the day? *

BODY BASELINE

Your physical starting point

Height - (cm) *

Weight - (kg) *

How many days per week do you typically train? *

Based on the past 3 months

What type of training do you currently do? *

Select all that apply

If you selected other, please explain which types of training you include in your routines

Can you currently run 5km without stopping? *

What are your average daily steps? *

How much sleep do you average per night? *

What is your average alcohol consumption per week? *

Do you have any injuries, health conditions, or dietary restrictions that may affect your participation in the program? *

Is there anything else about your health, lifestyle, or diet that you think would be useful for me to know?

COMMITMENT

Your intent for the next 90 days

What would success at the end of the 90 days look like for you? *

What do you believe could stop you from succeeding? *

In one sentence, who are you becoming over the next 90 days? *

Health Responsibility Acknowledgement *

I confirm that I am responsible for managing my own health, injuries, medical conditions, and dietary restrictions, and will consult a qualified healthcare professional before implementing any exercise or nutrition guidance if necessary.