Name
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First Name
Last Name
Email
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Pronouns
Birthday
MM
DD
YYYY
Describe your current struggles (behaviors, how often do you engage in them, how do they impact your life)
When was the onset of your disordered behaviors? Please share when you started to have a disordered relationship with food, and how it has transformed throughout your life until now.
What have you tried before? What has worked and what hasn't?
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What do you want to be different this time?
What specifically do you want to achieve in the next 3 months?
When you see yourself reaching your goal, what does that look/feel like? Describe what success means to you. Is it a feeling/quality of life?
How would you like to measure progress toward your goal? If you’re unsure, that’s okay! We can discuss this together.
When it comes to your relationship with your body, what is your biggest strength? And your biggest challenge?
What are your current thoughts when it comes to your body?
When it comes to your relationship with food, what is your biggest strength? And your biggest challenge?
What does your family's relationship with food and body like?
Do you have any dietary restrictions (allergies, sensitivities, etc.)?
Do you have any digestive issues?
Yes
No
Do you have a diagnosed health condition? If so, please describe, along with listing any prescription medications you take.
Yes
No
On a scale of 1-10 (10 being great!), how is your energy? Why do you think that is?
How would you describe your current stress level? What are your main stressors in life at the moment?
Medical Conditions (ex. diabetes, high blood pressure, high cholesterol)
What is your address?
And lastly, what's your favorite color? Trust me, I need it! You'll see why :D
By signing up with me you understand that I provide with a coaching program specifically for binging, emotional eating and body image. We will be working through everything that has led to your struggles and how to specifically reach your goals. If you struggle with mental health I encourage you to search for a mental health counselor in your area!
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Yes, I understand
No, I don't understand
