Love Yourself to Health/Diabetes Dominator Coaching Consultation Application
***IMMEDIATELY AFTER COMPLETING THIS APPLICATION, YOU WILL SEE IF YOUR APPLICATION HAS BEEN ACCEPTED. IF SO, CLICK THE LINK AND SCHEDULE YOUR DISCOUNTED COACHING CONSULTATION***

Well done! Taking the time to fill this questionnaire out shows that you're dedicated to taking action to create your own SUSTAINABLE healthy lifestyle through cultivating the life-changing daily self-love PRACTICES! Your answers will help make your session with Daniele tailored to your specific needs and goals.
#1 *
IN THE BOX BELOW, PLEASE ENTER YOUR NAME, EMAIL, PHONE NUMBER, AND SKYPE NAME (REQUIRED FOR ANY COUNTRY OUTSIDE OF USA OR CANADA). WITHOUT THIS INFORMATION WE MAY NOT BE ABLE TO CONTACT YOU.
Your answer
#2 *
IF YOU HAVE DIABETES ONLY - IF NOT, SKIP TO QUESTION 5 AND TYPE N/A IN BOXES 2-4! What type of diabetes do you have? At what age were you diagnosed? How old are you now? If you are filling this form out for someone else, please answer the questions and state your relationship to that person.
Your answer
#3 *
How many times a day do you check your blood sugar with a glucometer? Do you wear a CGM and/or an insulin pump?
Your answer
#4 *
What was your last Hemoglobin A1c value and when was it taken?
Your answer
#5 *
What do you generally have for breakfast, lunch, dinner, snacks? Do you have any challenges around food that you struggle with?
Your answer
#6 *
How many ounces of water do you drink per day?
Your answer
#6 *
What do you do for exercise? Are you satisfied with your level of physical fitness? If not, what (very specifically) are your challenges?
Your answer
#7 *
Please describe your overall outlook on life (as specific as possible). In what ways would you like to improve your mental/emotional health? Your spiritual health?
Your answer
#8 *
How many hours of sleep do you get each night?
Your answer
#9 *
What is your main challenge and what is your number one goal you are aiming to reach in the next 3 months?
Your answer
#10 *
How committed are you to do whatever it takes to make SUSTAINABLE, positive changes in your mind, body, spirit health habits and choices, and in your life overall? Rate your commitment using a scale from 1 - 5, where 1 = I'm completely satisfied with staying where I am currently, and 5 = I'm beyond ready to commit to making real changes that support all areas of my health and wellness
Your answer
#11 *
How did you hear about this opportunity for a discounted coaching consultation?
Your answer
#12 *
Please initial here to confirm that you understand that if you qualify: 1) you will be prompted to schedule a time for your discounted coaching consultation once you submit this form and 2) if you need to reschedule your discounted coaching consult after you initially schedule it, you must contact us at Coach@diabetesdominator.com to let us know within 24 hours of your originally scheduled session. If you do not show up for your session/do not let us know you need to reschedule ahead of time, you will not be able to schedule again.
Your answer
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