Weight Loss Program Self Referral Form

West Cook YMCA Weight Loss Program Referral Form
To qualify, participants must be at least 18 years of age and be able to participate in 1 session for 12 weeks.

This form is HIPAA Compliant.
Participant Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Gender (at birth)*

MaleFemale
Date of Birth*

MonthDayYear
Date
Race:*

White or CaucasianBlack or African AmericanAmerican Indian or Alaska NativeAsianNative Hawaiian or other Pacific IslanderOther
Highest educational or professional degree earned:*

Less than high schoolHigh school diploma or equivalency (GED)Associate's Degree (junior college)Bachelor's DegreeMaster's DegreeDoctorateProfessional (MD, JD, DDS, etc.)Other
I am confident in my ability to set and attain reasonable goals to achieve my desired long-term outcome.*

1

2

3

4

5

1 is Strongly Disagree, 5 is Strongly Agree
I am confident in my ability to maintain an exercise routine independently.*

1

2

3

4

5

1 is Strongly Disagree, 5 is Strongly Agree
I am confident in my ability to track food intake.*

1

2

3

4

5

1 is Strongly Disagree, 5 is Strongly Agree
I am confident in my ability to modify my food intake in ways that support my weight loss goals (e.g., portion control, avoiding emotional eating, choosing nutrient-dense foods, etc.)*

1

2

3

4

5

1 is Strongly Disagree, 5 is Strongly Agree
I give consent to receive email communication from YMCA of the USA and West Cook YMCA for the purpose of evaluating the Weight Loss Program.*

YesNo
As a leading nonprofit improving the nation’s health, the Y supports all individuals in achieving their health goals. The Y is always striving to learn more about program improvement. To that end, we are requesting your permission to collect your participation data:

I acknowledge data from this program will be collected by the local YMCA and may be shared with YMCA of the USA for purposes of evaluating and improving the Weight Loss Program. I authorize and acknowledge that I have read, understand, and agree to the above.
Signature*

Clear
Today's Date*

MonthDayYear
Date
Should be Empty:

West Cook YMCA Weight Loss Program Referral Form