Work with me one-to-one

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Hi there,

I’d love to know more about you!

Please answer the questions below as honestly as possible.

Don’t worry about getting this perfect… There's no right or wrong answer. Just fill it in the best you can without overthinking :)

Name your friends call you (or whatever you’d like me to call you): *

Your age *

Which article(s) on my website the10principles.com resonated with you the most?

Which of the following thoughts & behaviors describe what you’re going through and approximately how often you do them? *

BTW, I did them all for years and found a way to STOP. You can too! xo

Daily

Weekly

Never

restricting what I eat

bingeing

purging

emotional eating

feeling confused about what to eat

other

Do you do any of these other things?:

select all that apply

weighing myself

exercising if I think I ate too much

working out every day

when I eat something I regret I think "F*ck it! I may as well keep eating and start again tomorrow."

skipping a meal if I think I ate too much

counting calories

drinking diet pop

looking in reflective surfaces to check my size

eating diet food

eating reduced-fat food, like low-fat yogurt

trying to eat exact amounts of food

taking laxatives

being on and off diets

drinking skim milk

doing something symbolic to mark a new start

grazing

all or nothing thinking

eating while I cook

having lots of eating rules, tips and tricks like only eat the white of an egg

NOT eating a roughly balanced breakfast made mostly of whole foods

NOT eating a roughly balanced lunch made mostly of whole foods

NOT eating a roughly balanced dinner made mostly of whole foods

NOT eating a roughly balanced snack made mostly of whole foods when I’m hungry between meals

I'm either fully on a diet or fully off a diet

Other:

Any other preoccupying behaviors?

Which habit is the MOST disruptive in your life? *

Which diets have you tried?

Intermittent Fasting

Atkins

Weight Watchers

The Zone

Paleo

Other:

Anything else you want me to know?

How would your life be better if you weren’t preoccupied by food, weight and hunger? What activities would you enjoy more? How would you feel? *

What is your favorite way to spend your downtime? Do you have a hobby, sport or other go-to activity or interest? *

Have you read my book? *

Yes

Best day of the week and time for a complimentary 30 minute Discovery Call on Zoom? *

What time zone are you in? *

For example EST, GMT etc... or what country do you live in?

What's your email address, so I can write back to you?! *

I know Kelly’s NOT a doctor *

Yes

Required

I know Kelly is basing her support on what she did to make food and weight a non-issue for the last 23+ years. *

Yes

Required

Please confirm the following: 1) I understand that Kelly of The 10 Principles cannot provide medical treatment or diagnosis. 2) I understand that Kelly's coaching is not meant to diagnose, treat, or prevent any disease or illness. 3) I understand that I am responsible for my own health at all times, and I am advised and expected to use any coaching in conjunction with (not in lieu of) professional medical advice. 4) I understand that with any changes in lifestyle, there are certain risks involved, and I take full responsibility for my health and my choices. *

I confirm.

Required

If you haven't heard back within 24 hours, check your junk mail. Still no response? Send me an email via: kelly@the10principles.com. xoKelly ❤️

Will do :)

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