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First Name
Last Name
Phone
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Email Address
example@example.com
How can someone support you in getting to your goals? *
What is your commitment level to your personal results?
Type I’m sick of this and I will do whatever it takes.
Typei'm committed enough but I'm nervous!
Type I know I need help to make a change but I’m not sure if I’m ready to fully commit.
On a scale of 1-10, how important is it for you to fix these concerns and achieve your goals? *
Please Select
If we could fast-forward 3, 6, or 12 months from now and you felt completely in control of your body, how would your life be different? What would you be able to do or feel that seems out of reach right now?
On a scale of 1-10, how important is it for you to fix these concerns and achieve your goals? *
Type 0-3
Type 4-6
Type 7-9
Type 10
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