Lean Gut Mind Method Intake Form

1

Name

First Name

Last Name

2

Age

3

EmailPlease ensure this is accurate or I cannot contact you

example@example.com

4

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

Country Code

Phone Number

5

Where do you currently live? (Country and City)

6

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).

7

Why do you want to work with me?

8

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

10

What are the 3 most important goals you want to achieve for your health right now?

11

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)

12

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’m 100% ready and committed to making changes]

13

Our coaching is supportive, but we’ll also be honest and hold you accountable. If we identify habits, excuses or patterns that may be holding you back, are you open to being challenged when needed?

ABSOLUTELY NO

14

Our personalised 1:1 coaching programs are a premium investment, with options starting from $1,750 AUD. If accepted, are you financially ready to invest at this level in your health right now?

ABSOLUTELY NO

15

Funnel Status