Ready to ditch the diet and lose weight without giving up your favorite foods 💜

First Name

E-mail

How much weight would you like to lose?

0 - 25 lbs

26 - 50 lbs

51 - 75 lbs

76 - 100 lbs

100+ lbs

What is your motivation for wanting to lose weight?

Have you ever worked with a coach before?

Yes

No

Have you tried to lose weight before?

Yes, I lose weight but put it back on

Yes, but I didn't lose a significant amount of weight --- maybe 5 or 10 lbs

No

Length of coaching:

I really just need help with overcoming one obstacle and need guidance but I can apply it on my own

I'm interested in doing inner work, applying what I've learned, and working on a long-term basis for continued support and accountability

Timeframe to hire someone to help you break free and start working towards your goal:

Just looking with no definite date

Now

1-3 months

4-6 months

What would you say is getting in the way of you losing weight now?

What are some habits you normally have? (select all that apply)

Overthinking

Perfectionism

Avoiding

Complaining

Arguing with yourself

Being super critical of self

Playing the victim

Lack of self-trust

Waiting until the perfect moment

What is usually the reason you do not accomplish your goal?

Lack the skills

Not consistent

Talk self out of it

Do not have a clear plan to accomplish it (I know what I want but not how to get it)

Easily discouraged by comparing self to others

Easily discouraged by the negative things other people say

Working with me requires a small investment. Are you prepared to make the investment?

I cannot afford anything at this moment but I would like to hire you one day

Yes, I can pay $,1200 in full

Yes, I can make 3 monthly payments of $400

Have you been diagnosed or currently seeking treatment for any medical issues that may slow down your weight loss progress?

Yes

No

Have you been diagnosed with anxiety, clinical depression, ADHD or any other condition? If you responded “yes” to the previous question, how are you managing? If you answered “no”, please skip this question.

No longer struggle with it

Holistic health

Medication

Trying to manage the best way I can but it's a struggle

No issues

Are you currently seeing a counselor, therapist, psychologist or other mental health professional?

Yes

No

As a coach, do you understand that I cannot diagnose, treat or provide medical advice?

Yes

No

Of course, we want to make sure the relationship is mutually beneficial. Please complete the following intake form and if we believe it's a good match, we'll follow up with a link to hop on the calendar: