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Worksheet

Un-block Your Weight Loss Intake Form

This form is to help me get to know you better, so that we can make the most of our upcoming conversation!

UN-block Your Weight Loss Intake Session Form

1. ➜

First Name

2. ➜

Last Name

3. ➜

E-mail Address

4. ➜

Phone Number

5. ➜

What is your occupation?

6. ➜

Tell me why losing the weight now is currently your highest priority?

7. ➜

Tell me a litte bit about your struggle with weight loss.

8. ➜

What have you attempted in the past that didn't work? Why do you think it didn't work?

9. ➜

Have you ever had success with weight loss? If yes, what worked for you in the past?

10. ➜

Do your friends, family and partner help or hinder your health and weight loss goals?

Explain.

11. ➜

What is your biggest unanswered question when it comes to health and weight loss?

12. ➜

What supports do you think you need now to make worrying about your weight a thing of the past?

13. ➜

What questions do you need answered before you would consider enrolling yourself in a program to get the full support you need?

14. ➜

Anything else you would like me to know?

15. ➜

What attracts you to my approach and working with me specifically?

I look forward to reading your intake form and giving you the answers you need!

See you soon!

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