Intake Form

Chicken And Rice Fitness Coaching

Submit Our Intake Form Below To Kick-Start

Your Fitness Journey!

This should take 1-2 minutes and will give me a good sense of where you're at, and how I can help! 🫡

Firstly, How Old Are You?

*

I'm 15 Years or Younger
I'm 16-18 Years Old
I'm 18-25 Years Old
I'm 25-40 Years Old
I'm Older Than 40
No elements found. Consider changing the search query.
List is empty.

What are your main fitness goals?

*

Build muscle/ put on size
Lose weight/ lower my body fat %
Both A and B
Other
No elements found. Consider changing the search query.
List is empty.

Are you at a point right now where you are ready and committed to accomplishing your fitness goals?

Yes

No

How serious are you about getting my help to give yourself the best possible chance of achieving these goals?

*

I have $1000+ to invest in myself, and am 100% committed to reach the next level
I have $500+ to invest in myself and I'm willing to do what it takes
Money is tight right now... But, if the program guarantees results I can budget out $350+ to reach my goals
I have less than $300 to invest right now but am 100% serious about achieving my fitness goals and would consider it in the future
I am not serious enough to invest in my fitness goals at this time
No elements found. Consider changing the search query.
List is empty.

What is your occupation?

If I could show you a plan where you could enjoy food, drink in moderation, have a better quality of life, and get great results, would you consider working with me as your coach?

Yes

No

Last Step Brother!

Submit Your Contact Info Below, And I'll Reach Out!

I agree to terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from the business.

Okay!

This should take 1-2 minutes and will give me a good sense of where you're at, and how I can help! 🫡

Firstly, How Old Are You?

*

I'm 15 Years or Younger
I'm 16-18 Years Old
I'm 18-25 Years Old
I'm 25-40 Years Old
I'm Older Than 40
No elements found. Consider changing the search query.
List is empty.

What are your main fitness goals?

*

Build muscle/ put on size
Lose weight/ lower my body fat %
Both A and B
Other
No elements found. Consider changing the search query.
List is empty.

Are you at a point right now where you are ready and committed to accomplishing your fitness goals?

Yes

No

How serious are you about getting my help to give yourself the best possible chance of achieving these goals?

*

I have $1000+ to invest in myself, and am 100% committed to reach the next level
I have $500+ to invest in myself and I'm willing to do what it takes
Money is tight right now... But, if the program guarantees results I can budget out $350+ to reach my goals
I have less than $300 to invest right now but am 100% serious about achieving my fitness goals and would consider it in the future
I am not serious enough to invest in my fitness goals at this time
No elements found. Consider changing the search query.
List is empty.

What is your occupation?

If I could show you a plan where you could enjoy food, drink in moderation, have a better quality of life, and get great results, would you consider working with me as your coach?

Yes

No

Last Step Brother!

Submit Your Contact Info Below, And I'll Reach Out!

I agree to terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from the business.

Okay!

After submitting your application, I will set up a time for you and me to hop on a call!

On this call, we will discuss your current efforts and what we can do to get you where you want to be! So, even if now is not the right time, you will still receive a full hour of value from Ben.

Please submit all contact info on the last card so we can reach back out to you to setup our chat!