Application to the Plantiful Power Program

1
What's your full name?* This field is required.
First Name
Last Name
2
What's your Email?* This field is required.
example@example.com
3
Where do you live?* This field is required.
4
What's your phone number?* This field is required.
Area Code
Phone Number
5
How old are you? * This field is required.
6
What are you hoping to work on with me for the next 3-4 months?* This field is required.
I want to lose weight
I want to tone up
I want to build muscle
I want to get stronger
I want to feel good about myself again
I want to have more energy
I don't want to feel bloated anymore
I want to be healthy
I have a hormonal imbalance and would like to work on that
I have gut and digestive issues
I want to improve my relationship with food
I want to reconnect with myself
I want to heal from within
7
In your own honest opinion what is keeping you away from reaching these goals?* This field is required.
I am not sure how to start
I am not sure how and what to eat
I am not sure how to train
I need someone to keep me accountable
I am not motivated
I am lazy
I am very busy
I procrastinate
I am not sure
8
How soon can you get started if I help you achieve your health and fitness goals?* This field is required.
Yesterday
Today
This month, 100%
Next month
possibly, in the next few months
9
Let's talk financial resources for a second and offers (this is to make the best use of your time in the call)* This field is required.
I'm willing and able to invest financial & time resources into solving this problem ASAP, if of course you provide a legitimate solution
I don't have the financial resources, but I can get them if I need to. I'm willing to invest my time, if of course you provide a legitimate solution
I can't afford to engage anyone for help at the moment. I'd just like to get more information so when I'm in a position to invest, I can.
10
Will your partner/spouse influence your decision making?* This field is required.
YESNO
11
On a scale from 1-5 how important is it for you to reach those goals?* This field is required.
1
2
3
4
5
12
Have you tried diets/online coaching in the past? If yes, how was your experience?* This field is required.
Huge
Large
Normal
Small
Ok
Ok
13
What's your Instagram? (we will contact you on there)* This field is required.
14
How did you hear about Jess?* This field is required.
Instagram
Youtube
Podcast
Facebook
Recommendation
Other
15
Would you like to receive the newest updates about sustainable plant based nutrition, women's and hormonal health, emotional healing etc. via email?* This field is required.
Yes
No
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