Balance Plan Application

1

Your Name* This field is required.

First Name

Last Name

2

E-mail Address* This field is required.

3

Are you a Former or Current client?* This field is required.

I’m a former client

I’m a current client

4

When did you last work with PLT?* This field is required.

5

How long did you work with PLT for?* This field is required.

6

Who was your previous coach?* This field is required.

7

What goals did you achieve with your time at PLT?* This field is required.

8

What did you weigh when you started PLT?* This field is required.

9

What did you weigh when you left PLT?* This field is required.

10

What is your current weight?* This field is required.

11

What is your current medical situation?* This field is required.

12

How long have you been working with PLT?* This field is required.

13

Who is your coach?* This field is required.

14

Are you currently in maintenance with your coach?* This field is required.

Yes

No

15

How long have you been in maintenance* This field is required.

Less than 1 month

1-6 months

7-12 months

More than 1 year

16

What are your long term goals and what goals have you already achieved?* This field is required.

17

What is your current weight?* This field is required.

18

How much weight have you lost with PLT?* This field is required.

19

What is your desired weight range?* This field is required.

20

Tell us about your current medical situation?* This field is required.