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Weight Loss Breakthrough Session
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Today's Date
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YYYY
Email address:
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Your answer
First and last name:
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Your answer
Telephone number:
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Your answer
How have you come to learn about Jennifer and The Powter Weight Loss Academy?
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Facebook
Instagram
Jennifer's books (Diet Disruption / Stop Sabotaging Your Weight Loss)
Podcast
Website
Other:
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How much weight do you want to lose?
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<10 lbs
10-20 lbs
20-40 lbs
>50 lbs
On a scale of 1-10, how important is losing weight to you right now?
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Your answer
Jennifer typically works with women who are 40+ years old and are at a point in their life where they are able to invest (mentally, emotionally and financially) in solving their weight loss challenges for good. Does this describe you?
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Yes
No
Where are you currently in your weight loss journey?
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Your answer
What's your history with weight loss?
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Your answer
Why haven't you lost the weight yet?
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Your answer
Are you at a place in your life where you can prioritize yourself and this goal?
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Yes
No
Maybe
When will you be ready to start?
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Right away!
Within the next two weeks
I'm not sure
Are there any issues whether physical, emotional or circumstantial that would interfere with the likelihood of your success in our coaching program?
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Your answer
Do you have a prefered style of eating?
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I eat everything
I'm vegetarian
I'm vegan (100% plant based)
I omit gluten
I omit dairy
I have food sensitivities and allergies and base my diet around that
Other:
What is your primary reason for booking a Weight Loss Breakthrough call?
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I just want to get advice and make sure I'm on the right track towards my weight loss goals.
I'm tired of struggling on my own to lose weight and want to find the right weight loss program/coach for me.
Other:
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