Tell me about yourself

First name

Last name

Your email address

What is your age?

What is your height?

What is your current Weight?

What weight would you like to be at?

Have you reached Menopause?

What is your biggest challenge in losing weight?

How long have you struggled with your weight?

Do you or have you struggled with an eating disorder? If so when? Has your disorder been resolved?

Are you ready and willing to participate in this Program? You are ready to be emailing at least once per week and doing the worksheets? If not, then why - what is holding you back?

Why did you sign up for this Program? What do you hope to acheive at the end of the 3 months?

You understand that your Coach cannot do the work for you. Any improvement achieved during this program is because you did the work. Your Coach is simply a support person. Do you agree or disagree with the above statement?

You understand that if you make no improvements during this Program, it is NOT the Coaches fault. The Coach cannot make changes/improvements for you. You understand that any success is up to you. Do you agree or disagree with the above statement?

Why do you think this program will be different for you?

Thank you Response is sent!

Attuned Wholistic Services Inc.
Wellness & Weight Loss

Tell me about yourself

Operated by: Attuned wholistic services

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