2019 Pilot Program
What is your primary goal?
Other (If selected please specify below)
Other goal, please specify
Current weight (Optional, but will help to specifically calculate your goals)
The success of this program is based upon your willingness to implement changes. This is not a one-sized-fits all program, it is personalized to you. What you put into this program, is what you will get out. At this time are you willing to dedicate the time necessary and be honest and open-minded about making changes?
Commitment: I agree to fill out weekly check-in forms, read, interact and apply what is discussed in my weekly coaching e-mails/texts, and set up monthly calls with the Kansas City Dietitian. Type your name below to indicate agreement.
For my weekly coaching sessions I prefer:
Weekly E-mail Coaching
Weekly Video Text Messages (Majority of content will be video, any recipes or links will be sent via e-mail or text, standard texting rates apply)
Congratulations! I am so excited to start this journey with you. Within 24-hours of submitting this form you will receive an invoice, if you do not receive the invoice please check your SPAM. Your program will start the Sunday following your successful payment. Questions? Email
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Terms of Service