Vanessa Rogers' Mind-Body Nutrition 60-Day Program: Goals and Intentions Form

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Improvement of my health & wellness is a top priority in my life right now. *

Please share a brief summary of your food story & history in your health and wellness journey. What has worked? What has been difficult? *

I want a lasting solution and not a "quick fix." *

Yes

I recognize that it would be helpful to have a guide lead me in the right direction on this food + body journey. *

Yes

Maybe

I have struggled with building and keeping healthy habits. *

The food, health and/or body challenges I have experienced have impacted my life in the following way: *

I am willing to show up for myself, even when I'm not perfect. *

True

False

Three things that could derail my ability to reach my health goals are: *

If you take no action and do not change anything with regard to your health and wellness, what could happen? *

I believe in the power of the Universe.

Clear selection

Three qualities about me that will help me be successful in reaching my health goals are: *

Describe your biggest, wildest dream for your body and your health: *

I want to create change! I want to be free! *

Hell yes

Maybe

I keep my word: *

To myself

To others

All of the above

None of the above

Once I have surpassed my dreams and goals on this health journey and I'm feeling healthy, confident and energetic, I will be able to: *

I am ready and willing to do the work to get where I want to go! I am worth it! *

True

False

Please enter your email address *

Submit

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