6 Weeks to Glow Application

Email

First Name

Last Name

Have you worked with health/nutrition coach before?

Yes

No

How much weight would you like to lose?

0-20 lbs

21-50 lbs

51-75lbs

76-100 lbs

100+ lbs

Have you lost weight before?

Yes, but it was a few pounds

Yes, I lost a significant amount of weight and gained it back

Yes, I have lost weight but am at a plateau

No, I have not lost weight

What would change for you or what would you be able to do once you reached your goal weight?

In order to reach this goal, what do you feel like you need most?

Mindset to help me rebuild my confidence, get started or keep going

Nutrition advice because I really don't know what I should be eating

Lifestyle advice to help me make better choices and decisions on how to live so I fit in my new regimen and stick with it

Behavior changes to help me deal with mindless snacking, emotional eating, boredom eating or stress eating

What have you tried in the past to lose weight?

Are you in a position to invest today?

Yes, I can invest now

No, I am not able to invest anything right now but am interested in learning more about your services

Why is now the best time for you to start working towards your weight loss goals?

When would you like to hire someone to support you in your weight loss goals?

Now

1-3 months

4-6 months

I don't know

Spaces to 6WTG are limited. Why do you feel YOU are the best fit for this program?

What is your current profession?

Please list any medical/hormonal issues that may affect your weight loss journey.

Do you currently or have you ever dealt with disordered eating or an eating disorder?

No

Yes

How often do you find yourself eating out of either boredom, stress or due to emotions (both positive and negative)?

Daily

Weekly

1-3 Times Per Month

Rarely

Never

On a scale of 1-10, with 10 being the highest, how would you rate your daily stress level?

On a scale of 1-10, with 10 being the highest, how committed are you right now to investing into your health, happiness and wellbeing?

Are you currently under supervision of doctor, psychiatrist, or any healthcare professional for either mental or medical care?

Yes

No

Do you understand that I cannot treat, diagnose or prescribe any medical illness?

Yes

No

Apply for 6 Weeks to Glow Nutrition & Lifestyle Coaching Program

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