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First Name
Last Name
Email
Phone
What is your current profession?
On a scale of 1-10, with 10 being the highest, how would you rate your daily stress level?
How often do you eat when you are bored, lonely, stressed, anxious, sad or how often do you find yourself mindlessly eating?
Daily
A few times per week
A few times per month
Rarely
Almost never
How often do you eat take-out or dine at restaurants?
Daily
Weekly
A few times per month
Once per month
Rarely
Almost Never
Do you currently have any physical limitations or injuries?
Yes
No
Are you currently or have you ever been treated for depression?
Yes
No
Please list any medical conditions such as high blood pressure, diabetes, etc.
Have you ever been treated for disordered eating or any eating disorder?
Yes
No
Do you have children?
No
Yes
Are you currently pregnant or lactating?
Yes
No
What is your height?
4'8
4'9
4'10
4'11
5'0
5'1
5'2
5'3
5'4
5'5
5'6
5'7
5'8
5'9
5'10
5'11
6'0
6'1
6'2
6'3
6'4
6'5
6'6
6'7
6'8
6'9
6'10
6'11
What is your height?
What is your current weight?
How much weight would you like to lose?
0-15 lbs
15-30 lbs
30-45 lbs
45-60 lbs
60-75 lbs
65-100 lbs
100+ lbs
How much weight would you like to lose?
Do you currently track food and/or exercise? If so, what application do you use?
Do you currently have a support system to help you reach your weight loss goals?
No
Yes
If you need additional support with reaching your weight loss goals, are you able to financially invest in hiring a professional to help you?
Yes
Yes if there is a payment plan
Not right now
Are you ready to start losing weight right now?
It depends on what you have to say
I'm ready now
Book your time ➡️
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