INTAKE FORM

Basic Information

Full Name *

Age *

Country *

Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo, The Democratic Republic of the
Cook Islands
Costa Rica
Cote D"Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See (Vatican City State)
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran, Islamic Republic Of
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea People's Democratic Republic
Republic of Korea
Kuwait
Kyrgyzstan
Land Islands
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libyan Arab Jamahiriya
Liechtenstein
Lithuania
Luxembourg
Macao
North Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Federated States of Micronesia
Moldova, Republic of
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestinian Territory, Occupied
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russian Federation
Rwanda
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Eswatini
Sweden
Switzerland
Syrian Arab Republic
Taiwan
Tajikistan
Tanzania, United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
UK
Ukraine
United Arab Emirates
United States
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
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City *

Profession - What do you currently do for work? *

Average Work Hours Per Week *

Relationship Status *

Single
Relationship
Married
Married With Children
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Are You Location Dependent or Location Flexible? *

I live in one place
I consistently travel & work
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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

None
1 - 2
3 - 4
5+
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What type of training do you currently do?

Select all that apply

None
Strength training
Running
Other
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If you selected other, please explain which types of training you include in your routines

Can you currently run 5km without stopping? *

Yes
No
I don't know
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What are your average daily steps?

How much sleep do you average per night? *

Less than 6 hours
6 - 7 hours
7 - 8 hours
8+ hours
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What is your average alcohol consumption per week? *

None
1 - 2 days
3 - 4 days
5 - 6 days
6 - 7 days
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Is there anything else I should know before we begin?

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? *