First Name
Last Name
Phone
*
Email
*
On a daily basis, I deal with (select all that apply):
*
Depression
Anxiety
Worthlessness
Thoughts of suicide
Low energy
On a scale of 1–10 (1 being poor, 10 being excellent), how are your eating habits?
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10
9
8
7
6
5
4
3
2
1
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Are you looking to (Select all that apply):
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Build muscle
Lose weight
Tone up
Be overall healthier
Do you wish to improve your relationship with God?
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Yes
No
Unsure
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Are you in a position right now to invest in yourself?
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Yes
No
Unsure
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