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Hi there!

I am so happy that you are here, and so proud of you for taking this first step!

I work with women who are ready to commit to make their goals a priority, get healthy so as to switch into high performance mode without dieting, and rewire their limiting beliefs to transform from the inside out FOR GOOD!

If I feel that my programs & services are exactly what you need to make quantum leaps in your health & life, I'll share with you your best next step.

If it is not the right fit, I will provide you with resources to help you uplevel where you currently are so that you can reapply to work with me in the future.

I am so excited to be the coach to guide you in your path to alignment & success.

Let's get started.

Dina Merhbi

PS: mes services sont aussi disponibles en français. Si vous aimeriez que le formulaire soit en français, vous pouvez nous écrire : info@DinaMerhbi.com.

Email *

Last Name, First Name *

Age *

Gender *

Woman / Femme

Man / Homme

Other:

Please share how you came to find Dina. *

What are you currently struggling with when it comes to your health &/or your life? *

How long have you been struggling with this? *

How does it affect your life (how and whom is affect by this other than yourself)? *

Have you tried to work on it in the past? What was the result? (what type of coaching did you invest in the past) *

What are the 1-3 main obstacles you're experiencing in your health journey right now?
*

Can you relate to any of the following? *

Anxious / Stressed / Overwhelmed

Depressed

Emotionally eating / Binge eating / Stress eating / Night eating

Lack of energy / Tired of being tired

Feeling alone / lack of support

Lack of consistency / Focus

Never a priority to yourself / Feeling of not being worthy to take time for yourself

Insecure / lack of confidence

Feeling unfulfilled in life

Constipation &/or Diarrhea

Bloating &/or Abdominal pain

Food allergies/Intolerances

Nausea &/or vomiting &/or reflux/heart burn

Burping &/or gas

Other:

Required

Are there any health issues, medications & supplements that you want to share with me?
*

Any abnormal blood test results in the past 12 months? If yes, which ones? /
*

Height & weight
*

How often are you physically active per week? *

1-2 times per week

3-4 times per week

5+ per week

Please rate your fulfillment regarding your health. *

Please rate your fulfillment regarding your wealth / finances. *

Please rate your fulfillment regarding your relationships (love, family, friends). *

Please rate your fulfillment regarding your business / career. *

Briefly describe a typical day in your life, including your schedule, daily responsibilities, eating patterns and other commitments. *

When you envision your dream life what does it look like (imagine your ideal daily schedule, career/business, finances, your body & style, your health)? *

What’s one thing that you really want to make a reality in the next 6 months? Why is that important to you? *

On a scale of 1 to 10, how committed are you to taking your life to the next level by creating breakthroughs and overcoming the challenges you communicated above? *

Why do you want to work with Dina specifically, and what are you most excited about when it comes to working with her? *

Are you ready to invest to work on your goals alongside Dina? *

I am ready & committed to do the work with Dina inside her 6-month Rise & Thrive coaching ($1500/month). Send me the link to start!

I am ready & committed to do the work with Dina inside her 6-month Rise & Thrive coaching ($1500/month), but would like a talk with Dina first.

I would love to know how else I can work with Dina, other than private coaching

Other:

Required

Any additional information you'd like Dina to know prior completing this form? *

Send me a copy of my responses.

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