JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Kijia: Let's Chat about You!
Fill out the questions below with the most honest information.
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Name:
*
Your answer
Email Address:
*
Your answer
Phone Number
*
Your answer
Tell me about you. What habits are you trying to change? Why do you want to change them? How long have you been trying to change them?
Your answer
What are your personal goals? What do you want to be different or easier for you?
Your answer
Why do you think you have honestly failed in the past?
Your answer
If you picture yourself in 6 months, what would you like to have changed? How will making this change make life better for you?
Your answer
Are you the decision maker in attaining these goals?
Yes
No
Clear selection
What is your present level of commitment to address your health and reach these goals that relate to your health, nutrition, fitness and wellness?
not at all ready to change
1
2
3
4
5
6
7
8
9
10
100% committed to do what it takes
Clear selection
What are some of your favorite things?
Your answer
Can't wait to connect!
xoxo,
Ali
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Report Abuse
-
Terms of Service
-
Privacy Policy
Forms
