You can always press Enter⏎ to continue
21DC Application
1
Are you interested in getting in control of your body and the way it looks for the rest of your life?
*
This field is required.
This is what we do so just want to make sure :)
YES - I'm your girl!
NO - I'm just kicking tires
Previous
Next
Submit
Press
Enter
2
"This year, I am..."
*
This field is required.
In my 30's - ready to improve my body composition
In my 40's - embracing the exciting new chapter ahead
In my 50's - prioritizing my health and happiness
In my 60's - focused on feeling my best and enjoying life
Previous
Next
Submit
Press
Enter
3
How much weight are you looking to lose and sustain?
*
This field is required.
Less than 20 pounds
20-40 pounds
40-60 pounds
60 pounds or more
Previous
Next
Submit
Press
Enter
4
What have you tried in the past to lose the weight and sustain it?
*
This field is required.
Select all that apply
Specific Fad Diets
Health / Fitness professionals
Joined a gym or fitness classes
Tracked nutrition
Medical Treatments
None of the above
Other
Previous
Next
Submit
Press
Enter
5
What’s your BIGGEST motivation for getting in shape?
*
This field is required.
Select all that apply
To finally feel confident and proud of myself
To have the energy and strength to fully live my life
To take control of my health and create a stronger future
To become someone my family looks up to and depends on
Previous
Next
Submit
Press
Enter
6
What’s the biggest challenge holding you back right now?
*
This field is required.
Select all that apply
I’m doing everything right but still not losing weight
I’m too drained, stressed, or busy to stay consistent
I always put others first and my health comes last
I feel stuck, unmotivated, and doubt myself
Previous
Next
Submit
Press
Enter
7
Deep down, what are you most afraid of and ready to change?
*
This field is required.
Select all that apply
That I’ll never feel like myself again
That my health will decline as I age
That I’ll always feel uncomfortable in my body
That I won’t live up to my potential or truly enjoy life
Previous
Next
Submit
Press
Enter
8
How committed are you to solving this problem once and for all?
*
This field is required.
5 out of 10 - I’m not ready and prefer to stay the same.
7 out of 10 - I’m frustrated and eager to start.
9 out of 10 - This affects my life and I’m ready to act now.
10 out of 10: I’m all in and ready to change today
Previous
Next
Submit
Press
Enter
9
Your work life impacts your hormones, metabolism, and lifestyle. What is your full-time occupation?
*
This field is required.
Previous
Next
Submit
Press
Enter
10
Why NOW? Why is this important to you now?
*
This field is required.
Spots are limited to those ready for change.
Previous
Next
Submit
Press
Enter
11
Name
*
This field is required.
First Name
Last Name
Previous
Next
Submit
Press
Enter
12
Email
*
This field is required.
example@example.com
Previous
Next
Submit
Press
Enter
13
Phone Number
*
This field is required.
We will text you if you qualify. We will not spam you.
Previous
Next
Submit
Press
Enter
Should be Empty:
Question Label
1
of
13
See All
Go Back
Submit