Name *

First Name

Last Name

Phone *

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Date of Birth *

MM

DD

YYYY

How would you describe your current relationship with food? *

Select all that apply

Solid. I eat nutrient-dense foods that work well with my biology and I stop when I feel full.

Iffy. I’m not sure what I should be eating and when. I feel like I generally make healthy choices with occasional indulgences.

Rocky. I turn to food when I’m stressed, upset, had a bad day, etc. I struggle with cravings and can’t seem to get a handle on healthier behaviors.

Well, if I had to call it a relationship than I’d label it abusive. I either skip meals and don’t eat at all or overeat until I feel ill.

I'm really busy. Most of the time I don't even remember to eat because I have more important things to worry about.

Do you struggle with cravings for any of the following? *

Select all that apply

Sugar

Coffee

Soda

Cigarettes

Bread

Baked goods

Drugs

Alcohol

Social Media

Television

Toxic relationship patterns