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This form helps us understand your unique goals + emotional relationship with food.

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1. What's your biggest challenge with food right now? (Select all that apply)

Emotional eating

Binge eating

Sugar cravings/addiction

Portion control

Late-night eating

Restrictive dieting/rebound cycles

I don’t know—I just feel out of control sometimes

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What’s your relationship with food like? (Pick the closest option)

Food is comfort

Food feels like a reward or escape

I feel guilt or shame after eating

I want to be more mindful and intentional

I have a pretty health relationship but want better structure

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What have you tried before to change your eating habits? (Select all that apply)

Diet plans (keto, paleo, etc.)

Calorie counting or macros

Fasting

Working with a coach/nutritionist

Nothing yet—I’m new to this

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What would success look like for you? (Select all that apply)

Less cravings and more control

Freedom from emotional eating

Confidence in my food choices

Feeling more energized

Weight loss without obsession

Healing my relationship with food

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First Name ^*

Last Name

Email ^*

Phone Number

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