Survey - Diana Sugiuchi

I’m so excited you’re interested in the program! Please fill out this brief questionnaire so I can find out a little bit more about you and your goals.

Name

Phone Number

Age

In a few sentences describe your reason for seeking help.

Describe what ideal success would mean as we work together

Why are you not reaching your goals right now?

If we decide we're a good fit, how soon can you get started?

My weight goals over the next 3 months (please pick one):

I need to lose as much weight as I can, quickly I would like to lose weight but am more interested in long term changes to my habits The most important thing to me is changing my relationship with food and my approach toward my weight

What statement BEST describes you:

I am willing and able to invest time and resources to improving my health and changing my mindset around food I am curious about improving my health but not sure if now is the right time or not I am not willing to abandon a restrictive diet or change how I approach food and my weight