Healthy Habits Coaching Application
Hi! I'm so glad you're here. Please fill out this application to apply to work with me through the proven Healthy Habits framework. This is the first step to creating balance and confidence with food. I will be reaching out to you shortly to discuss the next steps and get started.
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Email *
Program Video 
What is your first and last name? *
What is your Instagram handle/name? *
Primary email address *
What is the best way to contact you to discuss next steps and moving forward? (email, instagram messaging, text - provide number, etc)
In your words, what is your number 1 goal you want to achieve by working with me? *
What are your 2-3 biggest struggles right now that you want to overcome? (e.g. Restricting and bingeing, fear of food, overwhelmed with knowing what and how to eat a balanced diet, emotional eating, managing stress, etc.) *
If you were able to overcome these struggles and reach your goals within the next 4-6 months of of this program how would that make you feel? What would that mean to you?
This coaching program is an investment in yourself. It is a 4-6 month commitment to change your life. You'll get individualized coaching, resources and guidance to help you stop dieting and find peace and balance with food forever.

I offer flexible payment plans and I do also take HSA and FSA. If we decide together that you are a good fit for this life changing program, what kind of financial commitment are you able to make at this time? 

Please choose all that apply.
**I do also accept Affirm Payments (payment options as low as $99/month)
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Is there anyone else involved in the decision making process? How do they feel about you hiring a dietitian? *
Do you have any reservations in moving forward with coaching? If so, please list them here. *
If we decide together that you are a good fit for this program, when would you like to get started?
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