Free Weight Loss Discovery Session Questionnaire

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Please enter your name and email address:* This field is required.Please use the same email address you used for any purchases you made of JoLynn's products.
First Name
Last Name
Please enter the same email you used to opt in before accessing this page
2
Where are you in the world?* This field is required.We need to know where you're at for the purpose of time zones for scheduling.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
3
Phone Number* This field is required.JoLynn will call you directly if you are in the United States.
Area Code
Phone Number
4
Please enter your Skype ID* This field is required.Only for international applicants
5
Are you a podcast peep? :) a.k.a. a loyal listener of The JoLynn Braley Show?* This field is required.Do you regularly listen to The JoLynn Braley Show?
Yes
No
6
What did you hear in JoLynn's podcast that inspired you to want to speak with her?* This field is required.
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In the past 3 months how many pounds have you lost and kept off?* This field is required.
8
If nothing were standing in your way, how many pounds would you need to lose to get to your healthiest goal weight?* This field is required.
2-5 lbs
5-10 lbs
10-20 lbs
20-50 lbs
50-75 lbs
75-100 lbs
over 100 lbs
9
Why do you think you haven't gained control of your eating and reached your goal weight yet?* This field is required.(Please be honest. This is a Get Real moment!)
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What are your Top 3 biggest weight loss challenges?* This field is required.
Binge eating
Emotional eating
Lack of motivation
Negative self-talk
I don't believe I deserve to be thin
I don't believe I'm worth it
Food addiction
Shame, Embarrassment, Self-hate
Lack of accountability
Can't figure it out alone
11
Describe your level of commitment to investing time, money and energy in your weight loss success:* This field is required.
I know without a shadow of a doubt that I am my greatest asset and I regularly invest in my own personal growth and mind-body fitness.
I am only interested in free offers and will not invest any money in myself or my mind-body fitness at this time.
12
Have you ever signed up for a coaching program before?* This field is required.Have you ever hired a professional coach?
Yes
No
13
Up to this point, what has stopped you from getting a coach?* This field is required.What has stopped you from hiring a professional coach so that you can get from where you are to where you want to be as fast as possible?
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How did that go?* This field is required.What happened? What was your experience? What were your results?
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How did you like your coach?* This field is required.Slide the slider on each question to indicate your happiness with your previous weight loss coach.
Ability to listen
Helped you stay accountable
Responsiveness
Friendliness
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Ability to listen
Helped you stay accountable
Responsiveness
Friendliness
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How willing and able are you to invest in YOU to get the results you deeply desire?* This field is required.
I have the financial resources to invest in my mind-body fitness and lose weight for good.
I have the ability to get the financial resources to invest in my mind-body fitness and finally lose weight for good!
I have no financial resources available to me to do anything different than what I am currently doing.
17
Throughout the years, what else have you tried to lose weight?* This field is required.Check all that apply
Calorie Counting
Intermittent Fasting
Fad Diets
Gym membership(s)
Weight Loss Pills
Home workouts
Weight Loss Shots
Journaling
Meditation
Weight Loss Surgery
Diet Clinics
Self-help books
Walking
Eating Clean
Online forums
Juicing
Keto
Smartphone apps
18
Do you recognize that the strategies, mindset, and approaches that have brought you to this point may not be suitable for reaching a new level of success with your eating habits and your weight?* This field is required.
Yes
No
19
This complimentary session is to determine whether I can help you break free of whatever is stopping you to move towards your ideal weight as quickly as possible. If it's a mutual good fit, is this something you want help with and are ready to commit to now?* This field is required.
YES! I want help with my weight and eating challenges and I'm committed to doing whatever it takes to achieve this now.
NO! I currently do not want help with my weight loss problems or eating behaviors.
20
What is the #1 result you'd want JoLynn to help you achieve? * This field is required.This is the result that if you could have it, you would be thrilled.
21
On a scale of 1 to 10 how confident are you that you could achieve that result if you can get JoLynn's help to do it?* This field is required.
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Why did you select that number on a scale of 1 to 10?* This field is required.
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We can ONLY accept 4 new clients maximum per month to work with, and we select applications based on those we feel are a BEST fit and most likely to get the RESULTS of breaking free of their eating and weight loss struggles. If you are accepted, how soon can you get started?* This field is required.Is this a Now Change or a "I can wait" kind of change you want to make?
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Let us know which of JoLynn's products or programs you recently purchased so that we can best assist you with your weight loss discovery session application.
No purchase
31 Days of Loving Yourself Thin
Coaching Session
Beyond the Plate: 21-day Prompted Journal for Emotional Eaters
Self-worth & Weight Loss: Empowerment On the Go
From Trigger to Triumph: 7-day Journey to Freedom for Emotional Eaters
How to Journal Your Way to Your Ideal Weight
Reclaiming Nourishment: 21-day Prompted Journal to Heal Food, Mother, and Self
Guided Meditation for Successful Weight Loss (any of various topics)
25
How did you hear about JoLynn Braley?* This field is required.
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Were you referred by a graduate of The Inner Self Diet?* This field is required.
Yes!No
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Please enter the first and last name of the graduate who referred you:* This field is required.
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We're only able to schedule sessions with those who really want to change and change is not always easy. With that being said, coaching is the fastest way to get from where you are, to where you want to be. Is there anything else you'd like us to know when considering your application for this complimentary weight loss session with JoLynn?* This field is required.
Include anything you'd like us to know that was not covered in the previous questions.
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Please complete the following and then click Submit at the bottom.* This field is required.
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