Start Here!

Use the form below to help me get to know you a little better before our call. Fields marked with an * are required.

After you click the submit button, you will be redirected to my calendar to schedule your no-obligation Lifestyle Consultation at a time that works best for you.

Thanks and I look forward to talking with you soon!

Vickie

Your Contact Details

First Name *

Last Name *

Email Address *

Phone Number *

Your Goals and Outcomes

Your Healthy Living GoalsDescribe where you would like to be 12 months from now. How would your life be different? What things, experiences or activities would be different? How would you feel about yourself and your results?

Your Biggest ChallengeWhat do you believe is the biggest challenge you're facing today regarding healthy living? What has prevented you from reaching the goals you listed above?

Medical DiagnosesYesNoHave you received any medical diagnoses that have prompted you to look for healthy living options? (If you check the box, we'll be sure to discuss them during your Lifestyle Consultation)

Fitness and ExerciseAre you currently involved in regular physical activity or exercise? If so, please describe (what type, how often, etc)

Weight Loss / Weight Gain HistoryDescribe your weight loss/gain history over the past 10 years. What weight loss programs have you participated in in the last 10 years?

Family CircumstancesAre you working on a plan for just yourself? Will your family members be participating? (If yes, please let me know first names and ages.) Are there any special family circumstances that might have an impact on your healthy living plan?

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