Healthy Living Coach™

Brooklyn, NY

You Have Been Referred To A Certified Health Coach

Hi, I’m Coach Charity.
Your health care provider ( Doctor, Nurse Practitioner) has referred you to Healthy Living Coach™  ONLINE HEALTH COACHING.
Coaching is provided for healthy meals and regular exercise.

The short term goal is to lose a minimum of 5% of your current weight. The intermediate goal is to lose 10% of the weight that you are today. The long term goal is to maintain the weight loss and continue in a pattern of healthy  meal choices and regular exercise.   

Coaching ONLINE means communication between you and your coach will include using text messages, emails and group video conferences such as zoom. Your coach will assign you homework exercise activity.  
If you answered yes, or, you would like more information before you decide, please provide best contact info and best time to contact you below.
Questions 7 to 15 require only a True or False response.
You want your answers to reflect where you are "now", not how you would like to be in the future.

Use this guide to measure your waist.
Planning for next week, based on your work and life schedule, please answer question below
The next step: If you indicated that you are interested in Health Coaching, you will be guided on the next step.   Expect communication via email, text and phone. If you have a question about something unclear on this form, send a text or WhatsApp to 929-213-7289. or email

Your Form has been successfully submitted!