Name *

First Name

Last Name

What are your goals? *

Check all that apply

Lose 10 – 20 lbs

Lose 20 – 50 lbs

Lose 50+ lbs

Eat healthier foods

Feel comfortable in my skin

Have more confidence

Love and accept myself

Have more energy

Find peace with food

What are your challenges? *

Check all that apply

Emotional eating

Sugar/carb cravings

Binging

Obsessing about food and your body

Eating in secret

Feeling guilty

Overwhelm

Self-sabotage

Which of these beliefs are stopping you? *

Check all that apply

“I don’t know what to do or where to start”

“I know what to do, I’m just not doing it”

“I eat healthy and workout – I don’t know why I’m not losing weight!”

“I’m afraid of failing”

"I'm worried it will be hard to lose the weight and keep it off"

“I don’t really believe I can do it”