1:1 Coaching Application

Name *

First Name

Last Name

Date of birth *

MM

DD

YYYY

Do you have an active, clinically diagnosed eating disorder? *

Yes

No

Do you have a history of any eating disorders? *

Yes

No

Have you been on diets in the past? *

Yes

No

Please check any that apply to you:

“I feel addicted to food.”

“I can’t keep certain food in the house, like crisps or chocolate, as I know I will just eat it all”

“I’ve been on and off of so many different diets and nothing seems to work.”

“I binge eat, overeat and I feel out of control around food.”

“I eat when I am feeling emotional, anxious or stressed.”

"I just want to eat normally and feel healthy and happy"

“I have a medical condition which needs managing with nutrition.”

"I feel like my food and body struggles are holding me back from living my fullest life."

"I am exhausted spending so much time and energy obsessing over food and my body."

Do you use/engage in any of the following? *

*I understand this is NOT a weight loss program

Calorie counting

Carb counting

MyFitnessPal

Noom

Weighing/Measuring food

Stepping on the scale

Portion control

Intermittent Fasting

Cut off eating by a specific time

Skipping meals

Engaging in exercise for the sake of burning calories

My 1-on-1 coaching is a four-figure investment in yourself. Knowing that you'll acquire the tools you need to eat without guilt, embrace your body, live a life of purpose and never diet again, are you ready to invest in yourself? * *

*I understand this is NOT a weight loss program

Yes

No