Filling out the form below will help me understand what your specific goals are in order for me to recommend the best program to fit your lifestyle.

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* 1. What is your name and how did you hear about me?

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* 2. What is your primary lifestyle goal?

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* 3. What is your secondary goal?

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* 4. Why is now the time you want to take steps to reach your goal?

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* 5. What change would you like see in the next 6-12 months?

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* 6. Do you take a multi-vitamin or any other supplements such as vitamin D or vitamin E daily?

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* 7. What do you currently eat for breakfast/lunch/dinner each day? Caffeine? List:

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* 8. How much would you say you spend on food for breakfast and lunch each day? For example, a salad at Panera with a drink is $13 so that’s one meal. Include trips to Donkin Donuts, Starbucks, etc.

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* 9. How often do you exercise? Are you interested in having a fitness plan created for you?

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* 10. On a scale of 1-100 (100 being the strongest), how serious are you about making your health & wellness a priority?

1 100
i We adjusted the number you entered based on the slider’s scale.

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