Intake Questionnaire

Weight Loss for Women Who Love Food

You are about to begin 16 weeks of weight loss and mindset coaching. The first step of your journey is to spend some time connecting with the “Future You” - the woman who committed to and has completed 16 weeks of work on herself, and who has achieved her goals in weight loss and mental/emotional management.

Visualize her life at the end of the 16 weeks. What is different for her? How is she feeling? What’s easier? What is she doing? How is she thinking about her body? Her lifestyle?

Name

First Name

Last Name

Goal

What is your goal, and when will you accomplish it by?

I will know I have accomplished my goal because:

(ex. I wear a size X, I weigh X pounds, I am eating like X, I exercise X times/week, etc.)

What are three things your Future Self thinks about herself?

What are three feelings your Future Self feels after she reaches her goal?

What are three things your Future Self is doing every day?

Take your answers above and brainstorm ways you can start thinking, feeling, and doing those things TODAY: