No BS Assessment

First Name

Last Name

Email

Have you worked with weight loss or mindset coach before?

No

Yes, worked great

Yes, but didn't get the results I wanted

Yes, currently working with one

Have you been diagnosed with anxiety. clinical depression, ADHD, or any other condition?

Yes, but I no longer struggle with it

Yes, but I'm managing it

No

Yes, I'm trying to manage the best way I can but it can be a struggle at times

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

Yes

No

How much weight would you like to lose?

0-20 lbs

21-50 lbs

51-75 lbs

75-100 lbs

100+ lbs

Have you tried to lose weight before?

No, this is my first time

Yes, I lost it but gained it back

Yes, but I never reached my goal

What is your age?

What is your height?

What is your current weight?

How often do you exercise?

Sendentary

Lightly Active (exercise 1-2 times per week)

Moderately Active (exercise 3-5 times per week)

Extremely Active (exercise 6-7 times per week)

What is your motivation for losing weight?

Do you have any other medical conditions such as thyroid issues that make it difficult to lose weight?

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

Yes

No

Hey Gorgeous!