Name *

First Name

Last Name

Birthdate *

MM

DD

YYYY

Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

I am willing to make changes in my diet. *

I'm ready to do whatever it takes, and I am excited to make changes even if they might be difficult.

Strongly Agree

Agree

Neutral

Disagree

I am willing to move my body every day. *

I already get significant movement in every day. Or, I'm ready, excited, and committed to getting some form of movement every day.

Strongly Agree

Agree

Neutral

Disagree

How much time do you have to commit to your health in the next 3-5 months? *

I have all the time in the world. Let's do this!!

I can adjust my schedule as needed, no problem.

I am very busy, but can make whatever time is necessary for my healing.

I am very busy, but can squeeze in a little time for my healing.

I do not have any spare time.

Are you able to invest financially in your healing? *

Yes

Maybe

No