Fuel Well Coaching Application

Name(Required)

First Last

Email(Required)

What state do you live in?(Required)

How did you find me?(Required)

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

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

What are your main challenges preventing you from reaching your goals?(Required)

My nutrition coaching program is a 3 month commitment. This includes 2 visits per month (6 visits total. 60 min initial, 30-45 min follow ups) Coaching pricing starts at $350 a month. Is this pricing structure within your budget? I accept FSA/HSA cards.(Required)

I am contracted with Blue Cross Blue Shield, Cigna, and Select Health. Do you have either one of these insurances, and if so, are you interested in learning about your coverage? *STARTING ON MAY 1, 2025, I WILL NO LONGER BE CONTRACTED WITH BCBS OR CIGNA*(Required)

My coaching sessions occur on Mondays between 6:30am-11:30am MST and Tuesdays 3-4pm MST January to March. Does this availability line up with yours?(Required)