Body Image Breakthrough Session Application

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* 1. How long have you been struggling with your weight or body image?

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* 2. What are the specific challenges you’re dealing with?

Negative Emotions and Thoughts about my body

Emotional Eating

Not enough knowledge

Lack of exercise

Late night eating

Other (please specify)

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* 3. What effect is a negative body image or extra weight having on your life now?

physical pain

lack of confidence that affects every area of my life

lack of enjoyment of life

lack of confidence at work so I don't do as well as I could

lack of confidence in relationships

poor role model for my children

health risks

negative effect on my intimate relationships

don't like clothes shopping or find it hard so I don't put much effort into my appearance

I don't go out or do social things

I spend too much money on food

I have feelings of guilt

I'm ashamed of myself

It's preventing me from doing something important with my life (write a book, be a speaker, be a healer etc.)

Other (please specify)

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* 4. If you don’t resolve it, what will the long-term costs be to you?

I may life out my days never truly enjoying life

I may have negative feelings about my body for the rest of my life

I may never be as successful at work as I likely could be

I may never have the relationship I really want

My children may struggle with the same pain

My health could deteriorate and my quality of life will be very poor

My intimate relationship could suffer or even dissolve

I may never create a strong social network of friends

I may never enjoy dressing well and feeling good in my body

I may struggle with diets and weight loss attempts for the rest of my life

I may waste a lot of time, money and energy trying things that don't work (i,e, new diets)

I may never do that important thing that I want to do (write that book, be a speaker, be a healer).

Other (please specify)

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* 5. Do you believe that your negative body emotion is contributing to a weight and/or food problem?

Yes, I completely believe that

No, I don't believe that at all

It's an interesting concept that I'd like to explore further

It's an interesting concept, but I don't think that's my problem

Other (please specify)

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* 6. Please tell me how you found my website.

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* 7. Thank-you for your responses! Please provide your email address, phone number and your time zone and I'll be in touch to schedule your Complimentary Body Image Breakthrough Session!