An 8-session online group
~Open to women and non-binary folks~

The following questions help me to get to know you and also understand if this course will be a good fit. If you have any questions, please feel free to reach out to me: amy@ladleandlotus.com

Event Timing: Tuesday, Jan 9- March 12, 2024. 2:30-3:30pm PST
Event Location: In person & Zoom (link sent out ahead of time)
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Full name *
Email *
Phone number *
What is the best way to reach you? *
Will you able to attend all or most of the sessions? (Zoom sesions will be recorded, for any that you can't attend live) *
What are you hoping to gain from this program?
What are some of your current challenges or questions around food?
Have you taken nutrition classes in the past? If so, please describe.
Do you follow any particular dietary guidelines?
Do you have any known food intolerances or allergies?
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If yes, please tell me what they are.
How do you wish to pay? *
I understand that although nutrition, movement, and lifestyle recommendations can be very therapeutic and beneficial it is not a substitute for a medical or psychological examination, diagnosis and/or treatment. I agree to assume full responsibility for any risks, injuries, or damages, known or unknown, which might occur as a result of participating in any programs or recommendations made. Since recommendations are based on the information I provide, I affirm that I have answered all questions truthfully and agree to keep Amy Hillman-Siracusa updated as to any changes in my condition. *
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