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Mindful Eating
Please fill out and submit this form. Be as open, and honest as possible, I PROMISE I will be the only one who reads this. The more detailed you are, the better I can prepare for our session!
25
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1
Name
First Name
Last Name
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2
Email
example@example.com
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3
Phone Number
Area Code
Phone Number
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4
Do I have permission to text you?
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5
What time zone are you in?
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6
Are you currently using one of my programs? If so, which one and how far along are you?
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7
Do you already have a yoga or mindfulness practice?
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8
Do you have any physical limitations?
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9
Do you believe you are an emotional eater? Please explain why or why not
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10
What types of things have you done in the past to lose weight? What has worked? What hasn't?
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11
Are there any foods you can't or won't eat?
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12
How tall are you?
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13
How much do you weigh?
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14
What is your gender?
Male
Female
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15
How old are you?
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16
Tell me about your WHY. Why do you want to lose weight? How will weight loss change your life?
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17
Is there anything else you think that I should know? Please feel free to be as honest and open as possible.
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18
When would you like to meet? Do you like mornings or evenings? What days work best for you? I will reach out to you with times that I have available.
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19
Do you prefer a Zoom or phone call? Either way we meet is fine with me, I want you to be comfortable!
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20
How did you find Mindfulness as Medicine?
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21
Do you agree that this Mindful Eating is a Mindfulness based coaching program and that it is not therapy or counseling?
I agree
I disagree
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22
Do you understand that I am not a doctor and it is your responsibility to check with your doctor before starting any new diet or exercise program?
agree
I disagree
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23
All conversations and information will be kept confidential unless something is disclosed that could bring harm to yourself or to others?
I agree
I disagree
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24
There is a 50% cancelation fee if a session is cancelled without 24 hours notice
I agree
I disagree
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25
Signature
Clear
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