Name
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First Name
Last Name
Email Address
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Phone number
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City and province/state
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How did you hear about The Food Coach?
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Occupation
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What other titles do you hold? (eg. Mom, Dad, partner, creative, runner, musician, etc)
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What are your goals for your health and well-being?
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What are you main health concerns, both physical and psychological?
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What is motivating you to invest in your health right now?
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Which statement best describes you?
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I am drawn to evidence-based science and will more motivated to change if I can see laboratory results for my body.
I don't need evidence. Just tell me what to do and I'll do it.
I need more than just a physical approach. I overeat for emotional/habitual reasons and need accountability, physical and psychological.
I'm not sure. I need help to get clarity.
None of the above.
If you decide that you would like to work with The Food Coach, when are you hoping to start?
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At that point, will you have the time to devote to creating change?
Yes, I'm ready
I'm not sure
It would be later
At that point, will you have the financial resources to devote to your health and well-being? (Note that nutrition programs start at 595.00 CDN for a 3-month program and the intensive Craving Lightness program (working together weekly for 3-12 months) start at 1695.00 CDN for 3 months. Depending on your location, taxes may be extra.)
Yes, I have the resources
I'm not sure
On a scale of 1-5, how much do you want to reach your health goals? (1 = I’m bothered by my issue(s) and am starting to think about doing something about it --> 5 = I am in so much pain physically, emotionally, mentally and/or spiritually, that I am ready to prioritize this once and for all.)
