Information Form
to request additional information on
CoachBJ's services


My role as a food coach is to guide and direct my clients to lead a more healthy life style by eating more plant-based foods and to have fun along this journey! So if you want to change to plant-based by 10% or go really strong at 95%, then I'm here to coach you. I'll individualize your plan to suit your lifestyle and goals. So that I might serve you better, please fill out the form below. I will contact you after I receive your completed form or call my studio office 717.446.0594 for additional information. I offer a free 1/2 hour consultation.


Information Form
Your NAME:

Your STREET NUMBER AND ADDRESS

Your CITY and STATE and ZIP CODE

Your E-MAIL ADDRESS

Your PHONE NUMBER and best time to reach

How would you describe your basic physical health:
Excellent
Good
Fair
Poor
I don't know but I need some coaching to eat healthier

Do you exercise regularly:
Yes No

If you exercise, type of exercise:
Cardio (walking, running, treadmill, etc.) Weights Both

Other members of your household may impact your shopping and eating habits.
Please check the one that best describes your household:

Myself and minor children
Myself and other adult/s (partner/spouse/parent/adult children/etc.)
Myself, minor children and other adult/s
I am in control of all shopping and cooking

If you have health issues or just want to stay healthy, please check those that apply:
Blood Pressure
Cholesterol
Energy
Diabetes
Digestive/Stomach
Weight
Others (explain in comment box below)
Currently, I don't have or know of any health issues, but I want to stay healthy.

Eating healthy whole foods, plant-based foods can help with many of the above issues and more.
If you would like to share additional concerns or family history issues, feel free to comment.
Or add any other comments below:


Coach BJ Reed can be reached by phone at her office 717.446.0594
If you wish, print this form, fill it in and mail it to the address below.

Thanks for your interest is getting on the healthy team!

  COACH BJ Reed
Piecemaking LLC
580 Governor's Court
Chambersburg, PA 17201
e-mail Coach BJ or Tom
717.446.0594
Copyright 2011-2016

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