Email Address

Age

How did you find me?

How would you describe your relationship to food and emotions?

What are your top three desires for improving this relationship and your emotional well-being?

What do you think are the biggest obstacles to making these changes?

How has your relationship to food, emotions, body affected you in daily life?

What have you tried in the past to improve this relationship?

What are you looking for in a behavioral food therapy relationship?

How many hours of sleep do you get on average?

On a scale of 1-10, what's your stress level, on average?

1= "What stress?"' 10 = "I cannot function!"

In a typical week, how much time do you generally allocate to activities that feel nourishing and important to your mental health?

Please list some activities as an example and explain your relationship to them in whatever way makes sense to you.

On a scale of 1-10, how ready are you to make changes and improve your well-being?

1 = "I'm considering whether change is worth it." 10 = "I was ready yesterday!"

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