Fuel Well Coaching Application

Name(Required)

First Last

Email(Required)

What state do you live in?

Who referred you?

What sports/physical activity, if any, do you participate in?

What's the main reason you are reaching out to me? Please share any goals you have.

What are your main challenges preventing you from reaching your goals?

My nutrition coaching program is a 2 month commitment. I have a weekly video visit option and twice monthly video visit option. (60 min initial, 30 min follow ups). You can go up and down by the month depending on your needs. (For example, you can start with meeting weekly for the first month and drop down to every other week for the second month). Weekly Coaching Option starts at $350/month depending on health condition. Every Other Week Coaching Option starts at $265/month depending on health condition. Is this pricing structure within your budget? I accept FSA/HSA cards.

I am contracted with Blue Cross Blue Shield and Cigna. Do you have either one of these insurances, and if so, are you interested in learning about your coverage?.

My coaching sessions occur on Mondays between 8:30am-5pm MST and Wednesdays 3:30-4:30pm. Does this availability line up with yours?(Required)