Lose Weight Without Giving Up the Food You Love!

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

Behavioral changes to help me stop mindless snacking, stress eating, boredom eating or emotional eating

What have you tried in the past to lose weight?

What is your profession?

On a scale of 1-10 with 10 being "extremely stressed", how would you rate your daily stress levels?

How often do you find yourself eating out of either boredom, stress, loneliness, anxiety, depression, other emotions or engaging in mindless snacking?

Daily

Weekly

Once Per Month

A Few Times Per Month

Rarely

Almost Never

On a scale of 1-10, with 10 being the highest, how committed are you to losing weight right now?

Why is now the best time for you to lose weight?

The calendar allows you to book your consultation within three days in advance. Are you ready to get started today?

Yes, I'd like to book a spot ASAP

Yes, I'd like to reserve a call within 3 days

No, I'm not ready right now

Do you currently track your food/calorie intake either on paper or using a digital application?

No

Yes

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, I understand

No

Ready to Lose Weight Without Giving Up the Food You Love?

Book your 1hr nutrition & weight loss consultation today for only $125!

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