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* 1. How long have you been struggling to lose weight?

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* 2. What other support have you invested in up until this point to try to lose weight? (choose as many as apply)

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* 3. What happened when you tried these things?

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* 4. What do you see as your biggest weight loss challenge?

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* 5. How much weight do you want to lose?

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* 6. How important is it for you to finally lose the weight for good on a scale of 1-10 where 10 is extremely important and 1 is not at all important?

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* 7. Please enter the following information so someone from my office can get back to you right away to schedule your private phone session. Thanks!

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