End Dieting Hell 90-Day Program Application Form
The purpose of this screening questionnaire is to determine whether this program is right for you. Please take your time to answer it as honestly and with as much detail as possible. This information will remain strictly confidential and will only be used to assess your suitability for a spot in the program. Thank you for your interest.
How long have you struggled with your weight?
Most of my life
What have you tried in the past?
Hired Personal Trainer
Other emotional release work
If you've tried other emotional release work, what was it?
What is your biggest challenge when trying to lose weight?
What are the feelings and thoughts you have most of the day around your weight and body image? What do you say to yourself?
What is your ideal long term vision for yourself around your weight and body image?
What will happen in your life if nothing changes AND will that be okay with you?
What is the biggest benefit you're looking to get out of this program?
How serious are you about ending dieting hell in your life?
4: VERY Committed! I'm serious and Ready To GO!
3: Starting to feel committed
2: kind of committed
1: Not committed at all
Do you want to be contacted to dive deeper in a 7-day Live in a Body You Love Intensive Hawaii Retreat? (ONLY 8-spots available)
Is there anything else you want us to know when reviewing your application?
How did you hear about us?
I've been on your email list for a while
A friend (please write who in the next box)
I don't remember
If someone told you about us, who can we thank for helping us spread the word? =) Thank you!
Should be Empty: