LEAN Gut Mind Method Intake Form

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Hi Beautiful,

Hi Beautiful,

Please fill out these next questions honestly so I can see if you are a good fit for my LEAN Gut Mind Method coaching services. If you are I'll be in touch soon to book a discovery call with you!

16Questions

1
Name
First Name
Last Name
2
Are you over 22 years old
Yes
No
3
Age
4
Email
example@example.com
5
Phone Number
Area Code
Phone Number
6
Where do you currently live? (Country and City)
7
Describe your health journey up until now including things you've tried (please let me know if you have a diagnosed eating disorder or history of one).
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Small
Ok
Ok
8
Why do you want to work with me?
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Large
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Small
Ok
Ok
9
What is your main complaint when it comes to your health?
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Ok
Ok
10
What gut problems/ symptoms do you suffer from?
Constipation
Diarrhoea
Bloating
Wind/ Gas
Abdominal Pain
Nausea
Vomiting
Reflux
Irritable Bowel Syndrome (IBS)
Unknown Food Intolerances
I don't have any gut issues
Other Types of Gut Issues
11
What are 3 goals you NEED to accomplish to improve your health?
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Small
Ok
Ok
12
Be honest, what is stopping you from accomplishing these goals right now? (The more specific you are the faster I can decide if you are a good fit for LEAN Gut Mind Method)
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Small
Ok
Ok
13
How ready and committed are you to start working on your goals/health right now? Choose a number from 1-10[1 = No commitment, I'm too busy right now] [10 = I am 100% committed and NEED to change my life!]
14
Do you have the resources, finances and time to invest in YOUR health now?
ABSOLUTELYNOT REALLY
15
If accepted into LEAN Gut Mind Method and my 1:1 Coaching, will you let me hold you accountable to your highest self and call you out on your self sabotaging behaviours or negative thinking patterns if necessary (including on our discovery call?)
ABSOLUTELY NO
16
Can you afford to invest at least $1,000 each month on your health (knowing that LEAN Gut Mind Method is a 3 month program).
ABSOLUTELY NO
Should be Empty:

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