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Application Form
Apply now to see if you are a good fit for Tiffany's programs!
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What brought you here, in this moment, today to click the "apply now" button?
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Your answer
What are your goals? What do you want to achieve by working with Tiffany?
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Your answer
What is getting in the way of your success? What barriers do you often come across?
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Your answer
Are you willing and open to learning different ways about how you can create balance in your diet?
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Yes
No
Are you regularly physically active?
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Yes
No
Other:
Would you call yourself an "athlete?"
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Yes
No
Other:
Do you regularly track calories or macros?
Yes
No
Sometimes
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On a scale from 1 (not ready) to 10 (let's dot it now!), how ready do you feel to make small sustainable changes?
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1
2
3
4
5
6
7
8
9
10
Is there anything else Tiffany should know before getting in touch with you?
Your answer
Full Name
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Your answer
Email address
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Your answer
Phone number
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Your answer
Date of birth
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MM
/
DD
/
YYYY
Zip code
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Your answer
Looking for insurance coverage? (unfortunately I don't accept Medicare at this time)
Yes (I accept Aetna, Cigna, United Healthcare, Empire, Emblem Health, BCBS, Oscar)
No
Other:
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