Raw Food Awakening
Change your life through Celia's signature raw food coaching program!
Name
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First Name
Last Name
Email
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example@example.com
Instagram user name
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@example
Where are you currently located?
Why would you like to do this coaching with me?
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What is your current lifestyle and diet like? (please be honest in order for me to be able to see if I can coach you properly)
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Make an honest report of what you eat and drink in an entire day of 24 hours, as detailed as possible (list all meals in detail)
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Do you currently work out? What kind of sports and how often?
Do you struggle with any health ailment?
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Please Select
Yes
No
Please describe any health struggles you currently experience
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Do you struggle with any mental ailment?
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Please Select
Yes
No
Not sure
Please explain in detail your mental health and sense of well-being on a daily basis, along with what changes you will like to see
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Have you ever dieted or had an eating disorder?
No
Yes, I have been dieting
Yes, I have had binge eating disorder
Yes, I have had anorexia
Yes, I have had bulimia
Other
Do you still experience eating disordered habits?
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Please Select
Yes
To a small extent
No
Not sure
Have you ever done a cleanse before?
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Please Select
Yes
No
Which kind? Please specify
What type of lifestyle do you currently have?
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Please Select
Standard American Diet
Omnivore with focus on health
keto
Vegetarian
Flexitarian
vegan
raw vegan
Fruitarian
Do you currently take any supplements? List which and in what dosis
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Are you wanting to change your diet for physical, mental or spiritual reasons?
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Please Select
Physical
Mental
Spiritual
A combination
What is your short term health goal?
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What is your long term health goal?
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What would you like to get out of this coaching with me?
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Are you willing to make changes in your lifestyle in order to achieve your goals?
Please Select
Yes
No
Depends
How did you find Celia?
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Please Select
Instagram
YouTube
Web Search
Website
Other
This program is a combination of nutritional advice, nutritional practices and spiritual work, based on Celia's own life experience and experience with healing suicidal depression and poor health
I understand
This is a high value ticket coaching program. If Celia decides to work with you, are you able to invest what it takes?
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Yes Indeed
No
Any comments?
You hereby declare that you are fully aware that Celia is not a trained health professional nor a Doctor, and that implementing any of the suggestions from Celia are at your own risk. The results you reap from this program depends on the amount of effort you put in. Celia will show you to the water, but only you can drink.
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I agree and comply
Submit
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