Name *

First Name

Last Name

Date of birth (participants must be 18+) *

MM

DD

YYYY

Do you engage in any of the following: *

Calorie counting

Carb counting

MyFitnessPal

Noom

Weighing/Measuring food

Stepping on the scale

Portion control

Intermittent Fasting

Cut off eating by ___ (Ex. I won't eat after 7 pm)

Skipping meals

Engaging in exercise for the sake of burning calories

Purging (induced vomiting/laxatives)

Purging (exercise)

Chewing/spitting

Do you wish you could just "eat normally"? *

Yes

No

Do you wish you could eat without guilt? *

Yes

No

Coaching sessions will be conducted through Zoom. Are you comfortable in a group video setting? *

Yes

Moderately

I am not comfortable

Group sessions are 60 minutes long and will be held at 1:00 pm EST on the following dates: 9/27, 10/11, 10/25, 11/8, 11/22, 12/6, 12/20, 1/3, 1/17, 1/31, 2/21. Can you attend a majority of the sessions? Please note that all sessions will be recorded and available to viewing. *

Yes

No

I have 1-3 hours to devote to this work each week. I understand that in order to get the most out of this program I will need to spend time completing different readings and modules on my own time. *

Agree

This group coaching program is an investment in yourself. You'll acquire the tools you need to achieve food freedom and never diet again. This 5-month program is $399 PER MONTH FOR 5 MONTHS or $1895 paid in full (HSA/FSA cards accepted). Are you ready to invest in yourself?

Yes!

No

I understand this is NOT a weight loss program. *

Agree