Full Name
*
First Name
Last Name
E-mail
*
Age (must be over 18)
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I've read the Nutrition Philosophy and understand what The Living Well is all about.
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YES
NO
How motivated are you to improve your health?
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1
2
3
4
5
Not Very
Let's Get Started
1 is Not Very, 5 is Let's Get Started
Have you worked with a nutritionist before?
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YES
NO
If yes, what did you like about your experience and what did you not like about your experience?
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Have you experienced any disordered eating habits in the past or currently? Explain.
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Have you been diagnosed in the past or currently with an eating disorder? Explain.
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Are you currently experiencing anxiety, depression, or any other emotional challenges? If yes, how are you managing this?
*
Do you currently have any other medical conditions that we should know about?
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Please list and and all other professionals you are working with or have worked with in the past on the above health situations.
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Are you willing to invest in yourself to reach your health and nutrition goals?
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YES
NO
What are your expectations for coaching?
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How will you define your success?
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Do you have anything else to share that we didn't ask you?
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What is your primary goal? Share as many details as you can to help us understand how we can help you.
*
Submit
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