THE GROUNDED RESET APPLICATION FORM

THE GROUNDED RESET APPLICATION FORM

The Grounded Reset™ is a structured, 12-week nutrition and lifestyle program designed to support mood, energy, weight, and daily routines through personalized, evidence-based nutrition and habit-building strategies. Our team includes certified nutrition and wellness professionals who support clients throughout the Grounded Reset program
Full Name

First NameLast Name
Contact Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What best describes what you’re currently struggling with (check all that apply)

Low energy / fatigueEmotional eating / cravingsWeight changesAnxiety or stressDepression or low moodBrain fog / focus issuesDigestive issuesInconsistent routinesOther
What would you most like to improve in the next 3 months?
How is this currently affecting your life?
Are you currently taking any medications or supplements?

YesNo
On a scale of 1–10, how ready are you to commit to improving your health right now?
How would you describe your current eating habits?
What would success look like for you by the end of this program?
Are you open to making changes to your nutrition and daily routines with support?

YesNo
Are you prepared to invest time, energy, and resources into a 12-week transformation program?

YesNo
If accepted, are you open to discussing program pricing and enrollment on your consultation call?

YesNo
By submitting this application, I acknowledge that The Grounded Reset is a structured nutrition and lifestyle program and not a medical service. A member of the Grounded in Gratitude team will reach out within 24 hours to schedule a follow up consultation call.
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