The Welch Way to Brain-Based Weight Loss Application

Please provide your best contact information so we can reach you regarding this application:

First Name *

Last Name *

Email *

Phone *

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What is your current height and weight? (This helps determine your starting point and your progress.) *

Why do you want to lose weight?

Improve my overall health

Feel better about my body

Look great for an upcoming event

All of the above

What is your weight loss goal?

Under 15 pounds

16-50 pounds

Over 50 pounds

Not sure but I know I need to lose weight

How many different weight loss programs have you tried in the past?

None - this is my first time trying

1-5

6-10

More than I can recall

Have you been diagnosed with any medical conditions that could affect your weight loss journey? (E.g., thyroid disorders, diabetes, hormonal imbalances, depression, etc.)

Do you have any food sensitivities or dietary restrictions? (E.g., gluten-free, dairy-free, keto, vegetarian, etc.)

What is your level of stress in your normal daily life?

I rarely feel stressed

I feel stressed several times per week

I'm stressed all the time but sleep is OK

My stress makes me lose sleep

How much sleep do you get on average?

9+ hours

7-9 hours

under 7 hours

It varies

Cravings - what do you tend to go for?

Sugar/sweets

Salty

Both

I don't have cravings

Where do you carry your extra weight?

Belly/abdomen

Hips/booty

Arms/legs

All over

Are there other areas you want to focus on?

What would reaching your goal weight mean to you?

What has made reaching your weight goal challenging in the past?

Family/friend influences or peer pressures

Lack of support of people I am around frequently

Self-sabotage

Tend to give up if I don't see quick results

Belief in my ability to lose weight

Unsure

Which of the following describes your situation best? (Select all that apply)

I am ready to invest in a program that provides lasting results.

I understand that meaningful health transformations require financial commitment, and I am prepared to fund my journey.

I am interested but would need to explore payment options or financing.

I am not in a position to invest financially at this time.

Which level of financial commitment aligns with your expectations for a high-quality weight loss program?

$500–$1,000

$1,000–$2,500

$2,500–$5,000

I’m open to learning more about what’s involved before deciding.

Thank you for filling out the application for the

Welch Way to Brain-Based Weight Loss .

Your answers will be reviewed within the next 2 business days and we will contact you with next steps.