Nutrition Coaching Intake Form

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    Nutrition Programs

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    Medical history

    Health & Nutrition

    Developing your Nutrition Program

    Our Coaching Relationship

    Acknowledgment, Participant Release & Cancelation Policy

    I understand and agree that it is my responsibility to inform Fit With Lou/Rebel Nutrition of any condition or changes in my health that might affect my ability to complete the program safely.

    I agree that Fit With Lou/Rebel Nutrition shall not be liable or responsible for any injuries to me resulting from my participation in the program and I expressly release and discharge Fit With Lou/Rebel Nutrition from all claims, actions or judgments as a result of any injury or damage which may occur in connection with my participation.

    I understand that Fit With Lou/Rebel Nutrition operates on a scheduled hourly appointment basis and that I must provide a minimum of 24 hours notice if I need to reschedule an appointment. The ability to reschedule depends on the availability of open sessions in the following 7-day period after the cancelled session. Where less than 24 hours notice is given, I understand that rescheduling will not be possible and I will be charged for the session. My coach will utilize that time to further develop my nutrition plan.

    Upon beginning the program, the contract will automatically renew on a month-to-month basis. I agree to give a 30-day notice of cancellation via email to in order to cancel the contract.

    By signing below, I confirm that all information I submit is correct to the best of my knowledge and that I have read and understood the participant release and cancellation policies.


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