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FOOD FREEDOM APPLICATION
Landing on this page means you were curious about what taking this first step towards making some lifestyle changes. And here you are! Whether you decide to fill out the application and proceed with your journey is up to you, but you know a part of you wants to take this step. A part of you is ready, no matter how scary this feels - on the verge of fear/anxiety can be excitement! How exciting indeed.
Congratulations! This is your first step towards reclaiming your health!! Let's do this!
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Email
*
Your email
Your Full Name
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Your answer
Age
*
Your answer
Your Instagram Handle
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Your answer
Country & Time Zone
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Your answer
What areas of your life are you currently struggling with & want to create change in? (Check ALL boxes that apply)
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Diet
Pain Levels
Fitness
Mindset
Boundaries
Healthy Habits
Work-Life Balance
Other:
Required
What do you need the most help with? Select ALL that apply
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Setting goals
Finding Gratitude in Your Daily Life
Creating Boundaries
Pain Management
Healing from Trauma
Support
Personal Empowerment
Working on Your Diet
Mindset
Confidence
Creating & Maintaining Healthy Habits
Other:
Required
Have you ever worked with an Empowerment Coach before?
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Yes!
No, you're the first
Other:
Please list any health diagnoses i.e.- Psoriatic Arthritis, SIBO, Autoimmune disease, Anxiety, Depression, etc.
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Your answer
How open to change are you?
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I am...
Very Open
Somewhat Resistant
Somewhat Open
Neutral
Coaching with Charlene Town includes a financial & personal investment. Are you ready to invest in Yourself?
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YES!
I'm not quite there yet
Is there anything else you think I need to know?
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Your answer
Send me a copy of my responses.
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