Online Consultation

Your Name (required)

Your Email (required)

Please answer the following questions.

Have you tried several diets and were unable to lose weight?
YesNo

Have you lost weight only to gain it back plus more?
YesNo

Are you preoccupied with thoughts of food?
YesNo

Do you eat when you aren't physically hungry?
YesNo

Do you eat until you feel sick or uncomfortable?
YesNo

Do you feel guilt and shame about your eating or body?
YesNo

Do you beat yourself up when you struggle to maintain changes?
YesNo

Do you feel like your eating is out of control?
YesNo

Your Phone Number (required)

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