Nutrition & Exercise Counseling Request

Phone:

West Family Y, 607-770-9622 ext. 406

We look forward to helping you reach your health and wellness goals. Please complete the Nutrition & Exercise Counseling request form. A Coach will contact you to set up your initial consultation. 
Name
Email
Phone
Are you a Y member?
 Yes  No
 
What are the most significant goals/concerns you wish to address? (Select all that apply)
 Cardiovascular conditioning  Muscular endurance  Muscular strength
 Muscle gain  Weight management/fat loss  Dietary habits/struggles
 General health and wellness  
Please list any health or medical concerns that should be considered prior to beginning exercise. (Please note: You will be asked to complete a brief health history during the intake appointment following submission of this request.)
Are there specific day(s) of the week that work best for you? (Please note: We wish to deliver the most effective service possible at the convenience of our members; however, we may be unable to accommodate all times and dates provided.)
 Monday  Tuesday  Wednesday
 Thursday  Friday  Saturday
 
Are thre specific time(s) that work best for you?
 6:00-9:00am  9:00am-12:00pm
 12:00-3:00pm  3:00-6:00pm
 6:00-9:00pm