Let's get started!
Please fill out this form to help start a plan for you to "Live your days as best as you can."

The information you provide below will give a better focus to motivate you throughout your journey to a daily lifestyle living with healthy habits. The goal is to make sure you get the support you need to achieve success throughout.

Congratulations on making the first step to DECIDE to say YES to unconditional support!
Sign in to Google to save your progress. Learn more
Basic Information...
First Name *
Last Name *
Email *
Privacy Policy: Promise to keep your email address safe at MailChimp.
Phone Numer *
xxx-xxx-xxxx
Facebook URL
If you have a "Like Page" with your health journey.      For Example: Mine is www.facebook.com/HealthyWitnessPage
Do you use a fitness or food tracker?
Tell which one(s)... (fitbit, my fitness pal, spark people, etc)
Health Journey Information...
Which best describes your health journey right now? *
"Health Journey" includes sleep, eating, exercise, and destress.
Which Support do you prefer? *
Group support will never "require" you to do anything unless you felt like it.
Tell me 3-5 Goals in Health, Life, Job, etc. *
In health, some people want to get in a smaller size and some want their blood pressure normal. // In life, some want to visit Niagra Falls or be a better parent. // In occupation, some want a promotion/raise, while others want to be self employed. This team is to help you succeed in all your goals.
Tell me your "WHY" for those goals. *
Now, dig deeper and tell me "WHY" on those goals you typed above. What is the reason for the goal(s)?
Tell me your biggest struggle in achieving your goal(s). *
What are your obstacles? What is preventing success? Etc...
Getting to know you...
Tell me a little about family life: Single? Married? Kids? Caring for parents? *
Status: Check all that apply to you now. *
Required
Tell me about your occupation (if applicable):
What do you do? What do you like most? What would you change?
Tell me about your recreation: *
Do you have a hobby or play sports? Where do you vacation?
Knowledge/Experience with Beachbody fitness/nutrition
I am an Independent Team Beachbody Coach.
Do you HAVE a TeamBeachbody.com Account? *
Remember you are NEVER obligated to buy any products to get FREE Wellness Coaching! It's Unconditional.
BB Products: Check all statements that apply to you: *
You do not have to "have or use" Beachbody products to receive Free Unconditional Wellness Coaching. Jackie will meet you at your resources for your goals.
Required
Beachbody Product Info: Check all that apply:
Your turn...
Do you have any questions or info for me?
Write your health questions here (maybe your weaknesses).
What is the best method to contact you?
Click Submit to complete form.
Your application for FREE WELLNESS COACHING is a "Free Account" with recipes, fitness, healthy habits encouragement, Individual and/or group support while you receive unconditional support, encouragement, and resources without obligation to make any purchases with your health friend Jackie (aka: @HealthyWitness) sticking by you all the way.

Thank you for taking time to decide to take charge of your health. Jackie can be reached at email healthywitness@gmail.com or call 904-685-1635 or message on Facebook www.fb.com/HealthyWitnessPage

Allow Jackie some time to read and process your answers below. Be prepared for a follow up from her to start your journey!

CLICK SUBMIT!
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