Rossell Fitness Recharge Application

Name*

First Last

Age*

Phone*

Address

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

Email*

Current weight (kg)*

Target weight (kg)*

Current clothing size*

Target clothing size*

How many times have you tried to lose weight before?*

Assuming that you are here because those other attempts to control your weight didn't work out, tell me what is going to be different this time around?*

Tell me what you think your main barriers are/have been when you have tried to lose weight in the past (please be honest here and go into detail - this will be useful for you as well as me!)*

Barriers are anything that get in the way eg time, motivation, religion, family, work, mindset, health, injury...

Please choose the most appropriate description for yourself*

Meat eater
Pescetarian
Vegetarian
Vegan

Do you have a facebook account?*

Yes
No

A lot of the coaching and community aspect will take place in the facebook group, so it is therefore recommended that you use your account to gain access to this aspect of the coaching. It is not essential however it is recommended.

Where do you see yourself in 5 years time if you do not take action now?*

Please go into detail here, I want to know how you think you will FEEL, LOOK, how your MOVEMENT will be different, your CONFIDENCE, your MOBILITY, your COORDINATION, your FLEXIBILITY, will you be able to run around with your kids/grandkids, will you be strong enough to pick them up for a cuddle - go deep here and get into the future!

We are going to be building a foundation in health, focusing on happiness, confidence, sleep, stress management and lifestyle. The power in this programme comes from the mindset coaching. Are you in a place in your life where you can commit the time, effort and energy into making changes? Are you ready to tackle the hard stuff, the habits and the difficult things that are not comfortable to talk about? If you are 100% ready to make changes and embrace health as the primary goal, please type your name into the box below.*

If you are not ready, please type NOT READY YET

I give my permission to be contacted by Nicola Rossell of Rossell Fitness using the information that I've entered in this application questionnaire. Please type YES into the box*

YES

Please visit the privacy policy document at www.rossellfitness.co.uk to understand how we hold and use your personal data.

RECHARGE TRAINING PROGRAMME