Application For Change

I will never ask you a question I’m not willing to answer myself. In fact, if I ever ask a question you are uncomfortable with, feel free to ask it back to me and I’ll give you my response first.

To view my response to this survey click here. These are the answers I would have given at the beginning of my journey.

Please be 100% honest. If you are worried about anonymity then use a fake name and email. I don’t care what your real name is until you decide to move forward in your weight loss journey.

If you are not ready to fill out the survey but have a question email me at:

However, before we can begin any weight loss consulting the form will need to be submitted.

Fields with a * required.

Name *
What are you willing to sacrifice to lose weight?
Are you and emotional eater?
Do you only feel happy with a full stomach?
Are you a reactive eater? Reaching for comfort food under times of stress?
On a scale of 1-10 how serious are you about changing your lifestyle?