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$397 CAD | $316 USD

First Name

Last Name

Street Address

Street Address Line 2

City

Province/State

Postal Code/Zip Code

Country

Phone

How did you hear about Empowered Eating?

Google Search

Instagram or Facebook

Through Friends or Family

Other

What are your biggest challenges right now related to your health and wellness?

Which of the following apply to you?

My weight has yo-yo'd up and down as an adult.

I have tried one or more weight loss programs in the past.

I consider myself an emotional or stress eater.

I often feel shame, guilt and/or out of control with eating.

I struggle with stress and burnout.

At times, I struggle to feel good about my body.

What are 3 personal health goals you hope to achieve in the next 3-6 months? Be specific.

Have you worked with a Dietitian before?

Yes

Do you feel ready to work on your relationship with food and your body at this time?

Yes! I am ready!

Is there any other information that you feel is important for me to know?

I have read and agree to the terms and conditions for enrolling in the Empowered Eating Program.

Yes

Thanks for submitting!

Alexa Jackson
Registered Dietitian | Nutrition & Health Coach
in Collingwood & The Blue Mountains, ON

Fax: 705-416-2145

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