Lean Gut Mind Method Intake Form

1

Name

First Name

Last Name

2

Are you over 22 years old

Yes

No

3

Age

4

EmailPlease ensure this is accurate or I cannot contact you

example@example.com

5

Phone NumberSo we can call you if you are a good fit for the program

Country 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).

8

Why do you want to work with me?

9

What is your main complaint when it comes to your health?

11

What are 3 goals you NEED to accomplish to improve your health?

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)

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

17

Funnel Status