Email *

First and Last Name *

Phone *

By providing my phone number, I agree to receive text messages from the business and may unsubscribe at any time.

Do you have a coach you'd like to work with? *

Heather Rodgers

Lori Carroll

Heather Lotstein

No preference

What program(s) are you interested in? *

Fitness Coaching

Nutrition Coaching

Functional Coaching

What have you tracked before? Select all that apply. *

Calories

Macros

Other

If you selected "Other", tell us more.

Do you have any current medical diagnoses?

Are you taking any medications? *

Not including exercise, how active are you on a daily basis? *

Sedentary: I sit most of the day.

Moderately Active: I sit throughout the day but am often up and walking.

Active: I am on my feet and moving or lifting most of the day.

Very Active: I am constantly moving, lifting, and rarely sit down.

What is your age? *

What is your height? *

What is your weight? *

What was your assigned sex at birth? *

Female

Male

Other variation

If you have a goal weight, what is it? Why is this your goal?

What goals do you want to accomplish by working with M2R Wellness?

Terms and Conditions

As changes to your diet, supplements, and/or activity level can be strenuous, we encourage you to consult with a physician prior to engaging in any new behaviors or activity changes. By selecting "Yes" below, you acknowledge that M2R Wellness is not a medical facility and our coaches are not doctors. We will always refer to medical professionals for diagnoses and treatment plans and are happy to partner with them to ensure you receive the utmost care on your wellness journey. *

Yes, I understand.

Change takes time and quick fixes are often unsustainable. By selecting "Yes" below, I understand that my Coach will create custom programs best suited to my goals and will provide guidance every step of the way. I understand that successful coaching is also my responsibility and I will follow the recommendations to the best of my ability. *

Yes, I understand.

Given the nature of gradual and sustainable changes, M2R Wellness requires a 3-month commitment for nutrition coaching and a 6-month commitment for functional coaching. By selecting "Yes" below, I understand this requirement and that cancellations are the initial term require 30 days notice. Cancellation requests that are made prior to the completion of the initial coaching term will be reviewed by M2R Wellness and handled on a case-by-case basis. *

Yes, I understand.

Signature *

Clear