YourOneLife Pre-Consultation Form
Thank you for getting in touch!

Please fill in this quick form so I can gather some information about you, your aims and your goals, to give me an idea of what you hope to gain from working with me, so we can decide if we'll be a good fit.

My services are online and are available anywhere. You do not need to live near me.      

Please fill in the form and I will be in touch

By completing this form, you agree that all information collected here and at your forthcoming appointment will be stored as per my Privacy Policy. You will be asked to tick the box to consent at the bottom of this form.

www.youronelife.co.uk/privacy-policy/

Thank you

Claire
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Email *
Name *
Age *
In your own words, what is your gender identity? *
Town / city / country *
How did you hear about YourOneLife Healthy Weight Solutions? *
Required
Phone number *
Preferred method of contact *
What would you like to achieve from us working together? Your main aim. *
On a scale of 1 to 10, with 1 being not important at all, and 10 being more important than anything else, how important is it to you to work on this? *
Why have you given that number? *
What have you tried before to manage your issues, if anything? *
What stops you from seeking help with these issues ? Please tick all that apply or add your own
What stops you from getting started with or keeping going with overcoming these issues? Please tick all that apply or add your own.
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Which of my services are you interested in finding out more about, to help you achieve your aims? Please tick all that apply. *
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If what you need is not listed, please describe what service you need.
Please describe any health issues and how they affect the issues that you are seeking my help for. *
Have you ever been diagnosed with an eating disorder? *
Is there anything else you would like to share with me? *
Privacy Policy *
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I understand that submitting this form will add me to the YourOneLife Mailing list to receive helpful information news, and special offers in relation to weight management. I understand I can unsubscribe at any time. *
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A copy of your responses will be emailed to the address you provided.
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