Private Weight Loss Program 
THE DISH ON NUTRITION

Are you ready to start your weight loss journey together? Fill out the form below to get started! 
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First Name *
Last Name *
Email *
Phone Number (xxx)xxx-xxxx *
Date of Birth *
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What inspired you to fill out this application? *
What are your 3 biggest struggles that have prevented you from reaching your weight loss goals?  *
What are your top goals that you want to achieve by working with me & joining this program?  *
What have you done or what are you currently doing in order to achieve your weight loss goals? *
What plans/ programs/ diets have you tried in the past to lose weight?  *
Have you worked with a dietitian before? *
How motivated and ready do you feel to start working on your goals? (Rate on a scale from 1-5 with 1 being low motivation/ not ready and 5 being high motivation/ ready.) *
Our Private Weight Loss Program costs $698 total for the 2 month duration ($349/month). The $698 payment is due before the first day of the program. Are you in a place to make that financial commitment at this time?  *
What questions do you have about the program?  *
How did you find out about The Dish On Nutrition?  *
I understand that the program is currently full and by submitting this form, I will be placed on a waitlist and will be contacted once a spot opens. *
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By submitting this form, you will be added to my mailing list. You may unsubscribe at any time. *
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After you submit your application, you will receive an email with next steps! 
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