Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Phone Number *

(###)

###

####

What do you feel keeps you from the life you desire? (click all that apply) *

Select all that apply

Fear of failure or judgment

Old patterns and self-sabotage

Not knowing where to start

Feeling like it's “too late”

Lack of support or accountability

Believing I have to be perfect to succeed

Other

What are your main struggles right now? (check all that apply) *

Select all that apply

Feeling burnt out or emotionally exhausted

Lack of self-love or confidence

Feeling stuck in "all-or-nothing" mode

Old patterns of self-sabotage

Difficulty setting boundaries

Overwhelm from trying to "do it all"

Struggles with nutrition or consistent movement

Other

What would you be genuinely happy about in your life right now? (click all that apply) *

Select all that apply

More time and freedom

Being able to quiet the noise in my mind

Better work-life balance

Waking up with purpose and clarity

Having more confidence in myself

Other:

What would make your life easier right now? *

Select all that apply

Clear direction and guidance

Systems or structure in my personal or professional life

Support in shifting my mindset and habits

Space to be seen, heard, and grow

Accountability and mentorship

Other

How would you describe your current relationship with yourself? *

Select all that apply

I'm learning to be kinder to myself

I'm my own worst critic most days

I feel confident in certain areas but not in my body

I don't know how to love myself without conditions

I'm ready to fully accept and celebrate myself

Other

When it comes to weight loss, where are you right now?

Select all that apply

I'm actively trying to lose weight

I've lost weight before but gained it back

I've tried every diet but nothing sticks

I want to focus more on health and confidence than the scale

I'm at my goal weight but still struggle with body image

Other