Free Weight Loss Consultation
Free Weight Loss Consultation
Name
*
Name
First Name
First Name
Last Name
Last Name
Email
*
Phone
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Preferred Method of Contact
*
Phone Call
Text Message
Email
Select your gender
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Female
Male
Current Weight
*
Select lbs or kg
*
LBS (Pounds)
KG (Kilograms)
Goal Weight
*
Select lbs or kg
*
LBS (Pounds)
KG (Kilograms)
What have you tried for weight loss?
*
Low Calorie
Keto
Low Carb
Dietitian
Personal Trainer
Fasting
Shakes/Pills/Injections
Other (Please Describe)
Other (Please Describe)
How long have you been struggling with your weight?
*
Have you lost weight in the past?
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Yes
No
If yes, how much?
Did you maintain your weight?
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Yes
No
If yes, how long?
If not, what was the reason you gained your weight back?
What has been preventing you from reaching your ideal weight?
*
What would ideal success look like for you as we work together?
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In a few sentences, please describe why you would like to work with me
*
How did you find me?
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Instagram
Facebook
Google/Internet Search
Friend/Family
Other (Please List)
Other (Please List)
Referee Name
Referee Name
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