Your Name (required)

Your Email (required)

Telephone (required)

What is your current weight?

Do you know your BMI?

Health Problems?

Are you taking any medication?

Do you consider yourself overweight? If so, how long have you been overweight?

When did you first start having trouble with your weight?

What have you tried in the past to lose weight?

What success have you had with other methods?

What is your relationship with food? Good. I eat when hungry and have a balanced diet.Varied. Sometimes good sometimes not so good.Bad. I eat lots of junk more than I should for the wrong reasons.Not sure.

Check all that apply (eating habits):  Eat when hungry Stop when satisfied Eat a varied diet full of fresh fruit and veg Eat when alone Eat in secret Feel guilty after eating Eat food that isn't healthy Eat all the time Can't resist eating junk food Eat at certain times of day more than others Eat certain types of food more than others Don't pay attention to any of this

Check all that apply (relationship with self):  Feel good about myself Feel indifferent about myself Not happy with myself Feel numb Feel bad about myself Hate myself Feel OK about myself

Complete the following:

What are the benefits if you lose weight?

What do you fear will happen to you if you don't lose weight?

What will happen if you lose weight?

Family History?

Are there any significant emotional events in your past that could be related?

Complete the following by filling in the blanks:
If there was something you believed was at the root of your problem that you could say about yourself beginning with I or I AM what would you say? Based on that response ask yourself: How do you know?
and what does that mean?

Request an appointment by contacting Brenda on 01527 853 424 or 0794 880 1229 or email info@buildingbelief.com. BOTH SESSIONS WILL BE BOOKED AT LEAST TWO (2) WEEKS BETWEEN SESSIONS FOR GREATEST BENEFIT.

You will receive an email confirmation upon booking. The terms of this offer are subject to availability and changes to the date, time, place you requested and/or confirmed. All appointments are subject to a 48 hour cancellation / reschedule policy. Failure to adhere to this policy will invalidate the offer. This offer is non-refundable.