Complementary Discovery Session Application
Please note: Completing this application form does not guarantee a Complementary Discovery Session with Kris Kern. Sessions are subject to availability of appointment times plus the Terms and Conditions listed at end of this application.

However, if you are really serious about achieving your weight loss goal and are ready to invest your time, energy and money towards achieving this goal please do complete the application and we at Mind and Body Revival Naturally will do our best to get you booked in.

Mind and Body Revival Naturally
First Name *
Your answer
Last Name *
Your answer
City: *
Your answer
Country: *
Your answer
Home Phone:
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Mobile Phone: *
Your answer
Email Address: *
Your answer
Age: *
Occupation:
Your answer
Are You Pregnant? *
Do you suffer with a Mental Health Condition? *
Please note: if you do have an existing mental health condition such as moderate to severe depression, epilepsy, schizophrenia or other personality disorders, hypnosis may be contraindicated and you should seek written permission from your doctor, psychologist, psychiatrist or therapist before proceeding. Please list conditions below.
Do you take prescription medications: *
(Certain medications may affect your ability to lose weight).
Imagine I had a magic wand and I just waved it so that you are now at your ideal weight and optimal health level. What would your life be like when you're enjoying all of this? *
What exactly does it look like? How does it feel to create this amazing life for yourself?
Your answer
What's the best thing about being at your ideal weight/shape and size and optimal health? *
Losing weight is just a journey (the means to the end), but what is it at the end of the journey that you really and truly want most?
Your answer
Why is it so important for you to achieve your ideal weight/shape and size and optimal health? *
What are the real underlying reasons or feelings you want to experience?
Your answer
How is your weight affecting your life? *
Does it affect your health, happiness, relationships, family, job or friends? Is it preventing you from doing specific things you want to do?
Your answer
If you don't take action to achieve your weight and health goals now, what are your worst fears? *
What are the real deep down, secret reasons that you want to change? What will you miss out on that you would really regret?
Your answer
What are you prepared to do to achieve your ideal shape and size? *
Please give as much detail as possible
Your answer
How committed are you right now to making changes to achieve your ideal weight, shape/size? *
On a scale of 1-10, how badly do you want this? (1 is not committed, 10 is "Nothing's going to stop me!")
Required
What are you prepared to give up to achieve your ideal shape and size? *
Your answer
What resources do you have to help you? *
Required
What have you done in the past to lose weight? *
Were you successful? If not, why not?
Your answer
What's stopping you from getting where you want to go? *
What roadblocks or challenges are currently stopping you from achieving your weight/health goals?
Your answer
Why is achieving your ideal weight, shape/size or optimal health such a challenge for you? *
Your answer
How do these challenges make you feel? *
Your answer
What are you currently doing that you know is holding you back from achieving your goal? *
Your answer
What other roadblocks or challenges might you run into? *
(This could include people who may not want you to change)
Your answer
What's missing for you in reaching your weight/health goals? *
Your answer
How would you rate your satisfaction with your life as it relates to your weight right now? *
1 is rock bottom, 10 is "I really love my life"
What is it costing you now and will it cost you in the future if you do not lose weight and become healthy?
Consider relationships, missing out on opportunities (with your family, career and business), financial, quality of life etc
Your answer
Is there any other relevant information related to your weight problem that would be helpful for me to know?
Your answer
Mind and Body Revival Naturally Complementary Discovery Session Terms and Conditions
Kris Kern and Mind and Body Revival Naturally respect your privacy. The information you provide in this questionnaire is completely confidential and will not be shared with anyone else.

However, please also note that submitting this questionnaire does not guarantee you will receive a Complementary Discovery Session. Kris's time is limited and she chooses to work only with people who are seriously committed to achieving their own success.

So please, be honest with yourself when completing this questionnaire and if you are not fully committed to making changes to achieving your success, do not press the Submit button below!

If Kris believes we could be a good match to work together we'll email or call you very soon regarding arranging an appointment time for your consultation.

Please understand that before you can embark on a journey to create the change you want in your life you need to have a road map to get you there. During the discovery session we'll help you to get clear on what it is that you want to achieve, what's been stopping you and how we can help you to get there.

Kris Kern and Mind and Body Revival Naturallywill do everything in our power to ensure your success in achieving your goals and desires. However please be aware that neither Kris Kern nor Mind and Body Revival Naturally can guarantee any specific results because your results depend greatly on you having realistic goals and expectations, your own serious participation in a program, and your individual biochemistry.

I agree with the above Terms and Conditions and that the information I have provided is true and correct *
Clicking the submit button below implies you agree with the Terms and Conditions above and that the information you provided is to your best knowledge correct
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