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Name*

First Last

Email*

Phone Number*

Time Zone*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Age Range*

20-29 years old
30-39 years old
40-49 years old
50-59 years old
60-69 years old

How did you find out about us? If someone referred you, please let us know.*

The work that I do is with emotional eaters. Which means that you use food for a purpose OTHER THAN to fuel and nourish. Keeping that in mind, which option best describes your current relationship with food?*

I do consider myself an emotional eater and use food to distract, procrastinate, numb out or avoid.
I don’t consider myself an emotional eater but sometimes I’ll overeat or eat when I’m not really hungry.
I don’t consider myself an emotional eater but I can’t seem to lose weight even though I eat healthy and exercise.
Eating isn’t my problem. My problem is when I’m upset, scared or anxious I lose my appetite all together.

What are your biggest challenges in creating and sustaining a healthy relationship with food?*

Do you turn to food as comfort or reward or to calm yourself or escape your feelings, especially after 3pm?*

Yes
No

If yes, approx. how often does this happen?

Every day
3-5x a week
Less than 3x a week
A few times a month

When you feel emotionally irritated or scared, does food make you feel temporarily calm, more grounded and secure (even if just for a few seconds)?*

Yes
No
Sometimes. And sometimes I lose my appetite all together.

During stressful times, do you feel you can gain weight without eating any extra food?*

Yes
No

How have the other areas of your life suffered because of your current relationship with food? (love/sex, career success, finances, happiness, social life)*

How does having your current relationship with food FEEL for you?*

Please list and describe what you have tried in the past to escape emotional eating and have a healthy relationship with food.*

In the methods you’ve listed in the previous question, what about them did NOT work for you?*

What would happen if your current relationship with food continues?*

When you dream about having a healthy relationship with food and a body you love, what do you see?*

What does your ideal relationship with food look like?*

How would you like to FEEL about your body and when you approach food?*

What possibilities would open up for you when you are free from the turmoil around food and your body?*

How would the other areas of your life thrive by having a healthy relationship with food? (love/sex, career success, finances, happiness, social life)*

Have you ever worked with a private coach before?*

Yes
Yes, but on a different area of my life (i.e.: life coach, career coach, business coach)
No, I didn’t know there were private coaches for this

If you haven't worked with a coach before, have you ever taken any weekend workshops, attended retreats, seminar or lectures on spirituality, emotional eating or overall self improvement?*

Yes
No

If yes, please describe what you have attended or experienced.*

Do you read self-help books? Please list your top 3 favorites.*

What has you looking for support around this NOW?*

When it comes to FULLY committing to your desire to have a healthy relationship with food, what gets in the way? (please select all that apply)*

I'm afraid no matter what I try, I'll fail
It'll be too expensive
The process won't be fun
I don't have support and accountability
I don't know what to do

Escape From Emotional Eating® is NOT your typical weight loss program and is NOT traditional nutritional health coaching. These powerful life changing programs are designed to facilitate a total transformation physically, mentally and emotionally with real results that last a lifetime. Therefore, the investment of time, energy and resources is significant. Is this in line with the level of support you are ready to receive and investment you are ready to make?*

Yes!
No
Maybe

In making the decision to invest in support around this, are you the sole decision maker? Or would someone else be involved in the investment decision? If so, who would that person be?*

So I can be of highest service, is there anything else you’d like to me to know?

Apply Now

Application Deadline – Thursday, February 9th @ 9pm Eastern

Only 5 Discovery Sessions Available – Submit Your App Now!

Escape Emotional Eating, Trust Your Body & Fill Your Soul
APPLY NOW!

Apply Now

Application Deadline – Thursday, February 9th @ 9pm Eastern

Only 5 Discovery Sessions Available – Submit Your App Now!

Escape Emotional Eating, Trust Your Body & Fill Your Soul APPLY NOW!

Escape Emotional Eating, Trust Your Body & Fill Your Soul
APPLY NOW!