CONTACT INFO:

Full Name

Email *

Phone *

Readiness to Change Questionnaire:

Are you looking to change a specific behavior?

Yes

No

Are you willing to make this behavioral change a top priority?

Yes

No

Have you tried to change this behavior before?

Yes

No

Do you believe there are inherent risks/dangers associated with not making this behavioral change?

Yes

No

Are you committed to making this change, even though it may prove challenging?

Yes

No

Do you have support for making this change from friends, family, and loved ones?

Yes

No

Besides health reasons, do you have other reasons for wanting to change this behavior?

Yes

No

Are you prepared to be patient with yourself if you encounter obstacles, barriers, and/or setbacks?

Yes

No

By providing my phone number, I agree to receive text messages and emails from the business at standard rates until I tell them to STOP.