Name
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First Name
Last Name
Email
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Confirm Email
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Phone
(###)
###
####
Location (City, State, Country)
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Tell me about your current situation. What are 3 things you’d like to focus on first if we were to work together?
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Is there a particular package you are interested in?
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Nutritional Therapy Foundations
Gut Healing
Compassionate Fat Loss
Macro Coaching
Hormone Healing
Can you share some concerns, challenges, or current conditions you are currently facing or struggling with?
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What thoughts, limitations or challenges do you feel are stopping you from committing to making the changes you are seeking?
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Can you tell me what you have tried so far to solve these problems?
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How ready, able and willing are you to invest in moving your health forward at this time? (time, resources, finances, current commitments)
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Has disordered eating been a part of your wellness journey?
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Yes
No
I'm not sure
If yes, have you received treatment for disordered eating and if you are comfortable sharing, where are you at in your journey?:
Are you a member of my nutrition program Empowered Nourishment?
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Yes
No
Anything else you’d like me to know?: