Create Her Nutrition: Program Interest Form

Create Her Nutrition: Program Interest Form
Thank you for your interest in Create Her Nutrition!This is an exclusive, small-group program for six amazing women who are ready to take control of their nutrition and health through personalised planning, weekly accountability, and advanced testing.

Please fill out this form honestly and completely so we can determine if this program is the perfect fit for your goals. We will reach out within 7 days to those who are pre-selected for the next steps.
Name:

First NameLast Name
E-mail Address:
example@example.com
Phone Number:
Format: (000) 000-0000.
Where are you based?
Example: Deptford, South East, London
Where did you hear about the Create Her Nutrition Program?

Other
What are your top three health/nutrition goals for joining this program?
Example: Increase energy, balance hormones/cycle, reduce inflammation, lose weight & etc.
Do you currently have a known health condition (e.g., PCOS, Fibroids, Endometriosis, Autoimmune disorder, Chronic fatigue)?
Please specify all details, diagnosis and date
Please describe your relationship with food and your body today.
Please specify all details
On a scale of 1 to 10, how consistent are you currently with healthy eating habits?

1

2

3

4

5

6

7

8

9

10

1 is Not Consistent, 10 is Very Consistent
Please list any current medications or supplements you are taking:
Please specify full details
Why is now the right time for you to invest in a personalized nutrition plan?
Please specify full details
What does "success" look like to you at the end of this program?
Please specify full details
The program includes hair testing, personalized 1-on-1 planning, and small-group support. What part of the program are you most excited about?

Other
Are you ready and able to commit the time necessary to follow a tailored nutrition plan, which may involve changes to your current habits?
The full details of the program investment will be shared following the application review. To secure your spot in this exclusive, limited group, a deposit is required. Are you prepared to make a financial investment in your health right now?
Any additional questions or notes for Cigdem?
Please specify in detail
Should be Empty: