Pre-Consultation Form
Congratulations for taking this positive step towards a healthier weight by getting in touch! Before your free 15-minute consultation appointment please could you fill in this quick form so I can gather some information about you, your aims and your goals to give me an idea of what you hope to gain from working with me.
My weight loss coaching services are online and are available anywhere. You do not need to live near me.
Please fill in the form and I will then be in contact.
Thank you
Claire x
* Required
Name
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Your answer
Age
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Your answer
Town / city
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Your answer
Gender
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Female
Male
Prefer not to say
Other:
Email
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Your answer
Phone number
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Your answer
Preferred method of contact
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Email
Phone
Video chat
How did you hear about YourOneLife?
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Your answer
What would you like to achieve from us working together? Your main aim.
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Your answer
On a scale of 1 to 10, with 1 being not important at all, and 10 being more important than anything else, how important is it to you to work on this?
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1
2
3
4
5
6
7
8
9
10
Why have you given that number?
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Your answer
What have you tried before, if anything?
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Your answer
What stops you from seeking help with weight loss? Please tick all that apply or add your own
I have given up hope of succeeding so I don't try
I don't feel motivated enough to get started or keep going
I don't know what to do
I should be able to do it on my own without help
Other things always seem more important
Nothing, I know I need some help and I'm ready for it
Other:
What stops you from getting started with or keeping going with weight loss. Please tick all that apply or add your own.
I am not motivated enough
I don't believe I can do it
I don't know how to do it
Nothing I do makes any difference
Nothing stops me when I put my mind to it
Other:
Clear selection
Which of my services are you interested in finding out more about, to help you achieve your aim? Please tick all that apply.
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Preparing for Successful Weight Loss online group course (8 sessions delivered live)
Preparing for Successful Weight Loss online do-it-yourself course
1:1 Weight Management Coaching
Members Club (monthly weight management membership club)
Webinars on Overcoming Barriers to Weight Loss
Free Facebook Group
Preparing for Successful Weight Loss e-book (just £9.97 until 31st March - see website to buy)
Other:
Required
To give me a rough idea of when is best to contact you, when are you available? Please tick all that apply. I will email or text you to arrange a specific time before calling.
0600-0900
0900-1200
1200-1800
1800-2100
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
0600-0900
0900-1200
1200-1800
1800-2100
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Is there anything else you would like to share with me?
Your answer
Privacy Policy
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By ticking this box I confirm I have read, understood and consent to Your One Life Privacy Policy and the collection of my data to be used in the purpose advised.
https://www.youronelife.co.uk/privacy-policy
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