Name
(Required)
First
Age ( Our program only suitable for over 18's )
(Required)
Phone
(Required)
Email
(Required)
How long have you been struggling with food and/or your body image ?
How would YOU describe your problem?
If I could wave a magic wand, how would you like your life to look like in 12 months’ time?
Have you sought help with this before?
Yes
No
Answered 'Yes', can you tell me what type of help, for how long, and if you felt it helped or not?
and if it didn't help, why do you think it didn't?
On a scale of 1-10, how motivated are you now to truly tackle and overcome this issue?
What would it mean to you to overcome your struggle with food, emotional eating and body image and move on with your life, free of all the stress associated with this issue?
Finally, is there anything else you would like to add for me to see ahead of our appointment
Phone
This field is for validation purposes and should be left unchanged.
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