WELCOME

With over 26 years experience in personal health + wellness in NY + LA, I am super excited to support you on your journey to optimal fitness. Please find your New Client Intake form below. Do your best to answer what you can, if you don’t know simply skip as needed. Contact us any time with questions or to check if the day/time you need is available prior to booking. See you soon + thanks!

treatments

Check all that you wish to experience in your session
Emotional shift, release negative energy
Hot Tea, Hot stone, facial cupping, back cupping, IT band cupping, physical yoga, assisted streteching , outdoor under trees, indoor fireside
Meditation reiki restorateive yoga, flower essence, detoxification, raw veggie juice, superfood smoothie , areas of focus upper body
redlight theapy mask

NEW CLIENT INTAKE

Name

First Name

Last Name

Email + Cell

Birthdate month/day/year

Main goals you wish to achieve through wellness coaching:

Ex: more energy, weight loss, better nutrition, mood + mindset, better muscle tone, flexibility, confidence, positive outlook, self esteem, emotion regulation, inner peace, strength, stamina, race training

Current age, height, weight:

Current types of exercise and frequency:

Current diet or nutrition:

Please list a typical day, each meal, snack and time of day for each:

Dietary Restrictions: ex: vegan, non-dairy, gluten free, food allergies

Medical Clearance + Medications

Please list any current known illnesses, injuries, or medical limitations that may require medical clearance to exercise, as well as any current medications and their purpose:

Current measurements:

If you want to track progress based on measurements, use the reference at the bottom right and a tape measure, please enter the following: neck, total around shoulders, L arm, R arm, chest, waist, hips, L thigh, R thigh, L calf, R calf

Check all forms of exercise you have experience with:

Also list any other in the box below

Treadmill

Briskwalking

Stationary Bike or Cycling

Free Weights or Weight Lifting

Yoga and Stretching

Equipment: which do you have on hand?

Ex: exercise mat, yoga mat, free weights, jumprope, resistance bands, thigh master, treadmill, Peloton, elliptical, foam roller

Favorite exercises you love doing:

Exercises or practices you prefer to avoid:

Preferred virtual method: zoom, facetime, other:

Preferred # of sessions per week? Best day/s and time for sessions:

Minor Consent

Our minor has consent to engage in exercise and wellness coaching, and will be provided with parental supervision as needed.

SESSION INFO

IN PERSON or VIRTUAL/ Available at PURE Wellness, your home, public park or private gym location and virtual via zoom.
Please plan to silence your phone and hold all other distractions for the duration of session.

WATER + FOOD/ Have water on hand during session. Please have a light meal or snack if needed about 1 - 1.5 hours before our session so you have proper energy. If you feel hungry right before our session, a low sugar juice, nut milk or small fruit is ok.

SPACE/ Designate a regular space for our sessions if possible, ideally quiet and private, at least 8ft in diameter when possible, and well ventilated.

EQUIPMENT/ Be sure to list all equipment you have in the form on the left, and have it on hand at our start time.

BOOKING DETAILS

Sessions are 60 minutes, longer per request.
Plan to put phone on mute and avert any other distractions for the duration.
Rate:
Under 21 - $88/hour
Over 21 - $132 $125/hour
Senior - $65/hour
Payment Method:
Venmo: @puretrail Last 4 digits of cell 4063
Zelle Transfer: Available upon request
Credit Card: Available upon request for an
additional 3% of transaction total

WELCOME

treatments

NEW CLIENT INTAKE

SESSION INFO

BOOKING DETAILS

MEASUREMENTS