• Let CYL² 🥗 Help You 👑 Live Your 🌷Best Life 💃🏾

    Let CYL² 🥗 Help You 👑 Live Your 🌷Best Life 💃🏾

    This is a secured form, and your information will not be shared without your permission. If you have questions or need help completing this form, please contact our team at CElliott@whatleyhealth.org.

  • Ready to get started? Sign up for our interactive lifestyle change program!

    Change Your Lifestyle. Change Your Life. (CYL²) can help reduce your risk of developing type 2 diabetes and other chronic conditions – with your commitment!

    Here’s what else you need to know:

    • Classes are interactive and engaging. Participation is key!
    • We are currently enrolling for a limited number of spaces.
    • The program is of no charge to you.
    • You will receive a year of support with a lifestyle coach:
      • First 6 months (Core Phase): You attend weekly Zoom meetings.
      • Second 6 months (Core Maintenance Phase): You attend twice a month Zoom meetings.
      • Each class session is one hour.
      • Make-up sessions: To keep you on track if you need to miss a class.

    Are you are ready to start your journey?

  • Are you able to regularly attend and participate in weekly class sessions?*
  • Format: (000) 000-0000.
  • What is your date of birth?*
     - -
  • What is your ethnicity? (ETHNIC)*
  • What is your race? Check all that apply.*
  • Your sex at birth: (SEX)*
  • Your gender as you identify: (GENDER)*
  • What is the highest level of education that you have completed? (EDU)*
  • How did you LEARN about the program?*
  • Who or what MOTIVATED you to sign up for the program? (ENROLLMOT)*
  • Did a healthcare professional suggest that you join the program? (ENROLLHC)*
  • Who is the primary payer for your participation in the program (PAYERSOURCE)? (Medicare and Medicare Advantage numbers are required by Medicare for billing purposes. Providing this information will not impact your coverage.)*
  • Have you ever been told by a healthcare provider that you have prediabetes?*
  • If you were told you have or had prediabetes, please check the blood tests you were given and provide your number. (If Medicare/Medicare Advantage is paying for your participation, they require your test numbers. Providing this information will not impact your coverage.)
  • Select all that apply:
  • Do you have a physical or visual challenge that may impact your participation in this program (VPDIS)?*
  • How would you rate your overall health?
  • Format: (000) 000-0000.

  • Please complete this prediabetes risk test.

    A total score of 5 or above means you may already have prediabetes, which increases your risk of getting type 2 diabetes. We will help you learn ways to reduce your risks. However, it is important that you contact a healthcare provider and ask for a test to determine your actual blood sugar level. Type 2 diabetes can be prevented.
  • How old are you?*
  • Are you a man or woman?*
  • If you are a woman, have you ever been diagnosed with gestational diabetes (diabetes diagnosed for the first time during pregnancy)?*
  • Do you have a mother, father, brother, or sister with diabetes?*
  • Have you ever been diagnosed with high blood pressure?*
  • Are you physically active?*
  • Look at the chart below. Find your height, then your weight range. Then move to the bottom of the chart to see your points. How many points does this chart say for your height and weight?*
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  • INTERNAL: Did the participant attend Session 0 (Orientation)? (SESS0)
  • INTERNAL: First Session Date
     - -
  • INTERNAL: Eligibility By:

  • Please remember to click the Submit button. Registration must be completed with the submission of this form before you are assigned to your class selection. A limited number of spots will be assigned first come, first serve.

    If you have any questions about enrollment, please contact us at mrocker@thewellnesscoalition.org.

    We look forward to supporting you on your journey!


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