Full Name *

Age (in years) *

Occupation *

Email address *

Phone number *

Height (e.g., 5'7" or cm) *

Current weight (e.g., lbs or kg) *

Goal weight (e.g., lbs or kg) *

How many children do you have? *

How long have you struggled with your weight or body composition? *

Which best describes your current challenge? *

What strategies or methods have you tried to address your challenge?

Are you currently taking a GLP-1 medication? *

If yes, which medication?

How long have you been taking it?

What is your primary goal with GLP-1 treatment?

Are you currently pregnant? *

Are you actively trying to conceive? *

If planning pregnancy, when would you ideally like to become pregnant?

If pregnancy is a future goal, what outcome is most important to you?

Which statement best describes you? *

How strongly do you agree with the following statement? "I deserve to invest in my health just as much as I invest in my family, career, and responsibilities." *

What is the biggest investment you've made in yourself over the past year? *

Why are you considering Elevate VIP specifically? *

VIP coaching requires participation, communication, honesty, and implementation. *

How soon are you hoping to begin? *

I understand that lasting change requires effort, consistency, and personal responsibility. *

I understand that Elevate VIP is a coaching program, not a quick-fix solution. *

I am ready to make myself a priority. *

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