WholeBody Trust Intake Form

I am excited to see if we are a good fit to work together as you end yo-yo dieting on your way to a healthier relationship with food as an Intuitive Eater in the WholeBody Trust: Intuitive Eating for a Peaceful Life Program. Once your intake form has been submitted, I’ll reach out via email (or Instagram (IG) Direct Message).

Name*

First NameLast Name

Email*

example@example.com

Phone Number*

Please enter a valid phone number.

Do you use Instagram?*

YesNo

What is your Instagram handle?*

How do you prefer I contact you?

EmailInstagram Direct Messaging

Describe your current relationship with food, eating and your body.*

How long have you been struggling with food and your body?*

5 - 10 years20 - 30 years>30 years

In 2-4 sentences, tell me your story. *

What are the top 3 challenges in your relationship with food that you want to fix in the next 6 months to a year? (Please be as detailed as possible).*

In relation to food, eating, and body image, what do you feel you need to work on the most? *

Where do you want your relationship with food and body to be in 6 months to a year from now? *

Are you new to Intuitive Eating?*

YesNo

What type of food and body healing work have you done, if any? What happened with those approaches? *

What's the core reason you want to work with me?*

Are you able to invest in the work to become an Intuitive Eater?*

Yes, I am ready to invest financially to become an Intuitive EaterMaybe, it depends on the cost.No, I don’t have the funds at this time

Is there anything else I should know?

WholeBody Trust™