Embrace You Weight & Wellness Clinician Referral

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Hi! Thank you for considering Embrace You Weight & Wellness for your patient's weight management needs. The mission of Embrace You Weight & Wellness is to empower our clients with a thorough understanding of their weight gain triggers and develop a personalized, scientific strategy for sustainable weight loss. Every patient receives an in-depth Weight Gain Triggers Strategy planning consultation with Dr. Sylvia Gonsahn-Bollie, our Lead Physician. Dr. Bollie is dual board-certified in Internal Medicine & Obesity Medicine. Patients then enroll in our four-month intensive program. The Embrace You program includes a weekly Movement Motivation (exercise) session, Mindset Meeting (education & support group), access to our private support forum, a customized meal planning strategy, and a monthly visit with Dr. Bollie to review their Weight Gain Trigger Strategy. After 4 months they have the option of continuing to meet monthly with Dr. Bollie.
Before joining the program, your patient will need to complete a complimentary consultation with Dr. Bollie to ensure they are ready for the Embrace You Weight & Wellness program.

What is your name? In what state do you practice? (Dr. Bollie can provide weight management coaching globally. She is licensed to practice medicine* in Washington, D.C., Maryland, and Virginia. *Practice medicine=prescribe medications) *

Please provide your contact details, including office address, phone number, fax number, and email. *

How old is the patient you are referring? (Dr. Bollie practices ADULT medicine, >age 18) *

What is the name of the patient you are referring? *

What is their concern regarding their weight? *

Why are you referring this person? (Please include relevant facts such as Weight, BMI,

What Stage of Change is your patient in regarding their need to lose weight for health optimization? Use your best clinical judgement based on your conversations.

Precontemplative- they aren't aware or willing to address their weight

Contemplative- they know they need to lose weight but no commitment to change or plan

Preparation- they have a plan to address their weight in place or are open to a dedicated program

Action-They have started taking steps to lose weight (it's okay to select this choice even if efforts haven't work)

Maintenance- Have made a lasting weight loss change or at weight loss plateau

Relapse- Previously lost weight but have returned pre weight-loss habits and/or regained weight

Clear selection

Do they have any obesity-related medical conditions? A few have been added below. *

Insulin resistance

Diabetes Mellitus Type 2

HTN

HLD

Obstructive Sleep Apnea

Coronary Artery Disease

History of Stroke

They do not have an obesity-related medical condition

Other:

Required

Please provide any additional medical history.

What is your patient's email address? By providing this information you are confirming that the patient has given permission for Embrace You Weight & Wellness to contact them regarding scheduling a complimentary, non-binding weight consultation with Dr. Bollie. Please note their information will not be provided to any third party vendor. *

Thank you for assisting your patient in optimizing their health through sustainable weight loss! We will send them an email invitation for consultation and keep you updated on the outcome. Please feel free to leave any closing questions or concerns below.

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of embraceyouweightloss.com. Report Abuse

Forms