Intake Form- The Consistency Reset

Basic Info

Full Name *

Email address *

Age (Optional)

How would you describe your current eating habits? *

Very inconsistent

Somewhat inconsistent

Pretty consistent but want improvement

What do you struggle with MOST right now? *

e.g. snacking, emotional eating, overeating, lack of structure, deciding what to eat

How many days per week do you realistically feel you could focus on improving your nutrition? *

2-3

3-4

What are your main goals for the next 3 months? *

Why is this important to you right now? *

Which statement best describes you? *

I'm looking for a quick, strict plan

I want something flexible but still structured

I want help building long-term habits

Are you open to weekly check-ins, adjusting habits gradually, and trying a flexible approach (not all-or-nothing)? *

Yes

What has NOT worked for you in the past? *

This is a 3-month program focused on consistency, not perfection. On a scale of 1-10, how committed are you to making changes right now? *

1 is the least and 10 is the most

If you join, are you willing to start June 1st and participate fully? *

Yes

Not sure

Are you comfortable with a small group setting (4-6 people)? *

Yes

Do you have any dietary restrictions or important considerations? *

What is your name on Facebook? *

The group support will take place on Facebook in a private group.

Is there anything else you'd like me to know? *