Spirit of Wellness Questionnaire

When is a good time for a 60 minute phone consult?

Please provide 3 time ranges.

Which best describe you now?

(Check all that apply)

Which describes you?

Do you live with others?

If so, please describe your household and how that effects your eating?

If you would like to lose weight, how much would you like to lose?

Do you have any health problems currently?

Please explain.

What kinds of stresses are getting in your way of being happy & healthy now?

What thoughts have you identified that make it hard for you to consistently eat healthfully?

How would you like things to be different for you in 6 months?

On a scale of 1 - 10, how important is it to you to make the changes needed to get healthier?

(1 = Least,  10 = Most)

Thanks for filling out this questionnaire.

Please click "submit" and Delisa will contact you soon about scheduling a free call.

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