Personal History

Please fill out the application below to give me a better understanding of your story and so we can make the most of our time together. Provide as much detail as possible. Trust that all information will be kept confidential. 

Name *
Phone Number *
Phone Number
Address *
Which statement(s) best describes your relationship with food and your body now? *
Check all that apply.
Don't hold back!
Are you experiencing health issues related to your eating and exercise habits? *
Describe in detail what has and has not worked for you.
Do you use food as motivation, support, reward, and/or to calm your nerves, especially when you feel overwhelmed or have a difficult task at hand? *
Do you feel strongly compelled to eat before you even have a chance to evaluate your feelings? *
Do you experience bouts of fatigue that can seemingly only be remedied with food? *
Are you sensitive to sugar, caffeine, alcohol, and/or highly processed foods? *
Do you feel out of control around trigger foods in your home and/or free food at events (au d'oeuvres, buffets, party snacks)? *
Do you take comfort in control, structure, and self discipline? *
Do you consider yourself knowledgeable about nutrition, fitness, and/or holistic health? *
Despite your current knowledge, are you confused about what foods and exercise are right for your body? *
Do you consider yourself a perfectionist, often labeling your thoughts and actions as good or bad? *
Also include if your routine and attitude around food and your body varies, based on your circumstances, stress level, etc.
Do you feel overwhelmed in large groups or when asked to perform tasks in front of others? *
Do you find yourself turning to others (and the Internet) for answers rather than listening to yourself? *
Do you meditate or have interest in starting a practice? *
Please share all of your thoughts.
Do you consider yourself a spiritual person? *
Have you ever worked with a coach specializing in emotional and/or disordered eating? *
Have you attended any events, workshops, retreats, seminars, or lectures on food, spirituality, or self empowerment? *
When it comes to committing to deep healing, what fears and limiting beliefs come up for you? *
Check all that apply.
My program goes far beyond traditional nutrition and health counseling. Shifting consciousness at such a deep level results in permanent physical, mental, and emotional transformation. It requires significant passion, engagement, and investment. Are you ready to make this type of commitment and receive the support you need to achieve long-lasting freedom? *